2002 - University of Washington Bone and Joint Sources
2002 - University of Washington Bone and Joint Sources
2002 - University of Washington Bone and Joint Sources
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<strong>University</strong> <strong>of</strong> <strong>Washington</strong><br />
Department <strong>of</strong> Orthopaedics<br />
<strong>and</strong> Sports Medicine<br />
<strong>2002</strong> Research Report
UNIVERSITY OF WASHINGTON<br />
Department <strong>of</strong> Orthopaedics<br />
<strong>and</strong> Sports Medicine<br />
<strong>2002</strong> Research Report
UNIVERSITY<br />
OF WASHINGTON<br />
SCHOOL OF<br />
MEDICINE<br />
Department <strong>of</strong> Orthopaedics <strong>and</strong> Sports Medicine<br />
<strong>University</strong> <strong>of</strong> <strong>Washington</strong><br />
Seattle, WA 98195<br />
EDITORS:<br />
Fred Westerberg<br />
Frederick A. Matsen III, M.D.<br />
DESIGN & LAYOUT:<br />
Fred Westerberg<br />
Cover Illustration: “Guernica”<br />
Picasso, Pablo (1881-1973) (c) ARS, NY. Guernica, 1937.<br />
Oil on canvas, 350 x 782 cm<br />
Copyright John Bigelow Taylor / Art Resource, NY<br />
Museo Nacional Centro de ArteReina S<strong>of</strong>ia, Madrid, Spain
Contents<br />
Foreword .................................................................................................................................................................... 1<br />
My Dad The Shooter ................................................................................................................................................. 2<br />
James W. Strickl<strong>and</strong>, M.D.<br />
Visiting Lecturers ....................................................................................................................................................... 5<br />
Lynn T. Staheli, M.D., <strong>2002</strong> Distinguished Alumnus ............................................................................................... 6<br />
Is the Absence <strong>of</strong> an Ipsilateral Fibular Fracture Predictive <strong>of</strong> Tibial Pilon Fracture Severity ............................. 7<br />
David P. Barei, M.D., F.R.C.S.(C), Sean E. Nork, M.D., Carlo Bellabarba, M.D., <strong>and</strong> Bruce J. Sangeorzan, M.D.<br />
Intramedullary Nailing <strong>of</strong> Fractures <strong>of</strong> the Proximal One-Quarter Tibia ............................................................. 9<br />
Sean E. Nork, M.D., David P. Barei, M.D., F.R.C.S.(C), Jason L. Schrick, B.S., Sarah K. Holt, B.S.,<br />
<strong>and</strong> Bruce J. Sangeorzan, M.D.<br />
Complications Associated With Internal Fixation <strong>of</strong> Comminuted, Bicondylar Tibial Plateau Fractures ......... 12<br />
David P. Barei, M.D., F.R.C.S.(C), Sean E. Nork, M.D., William J. Mills, M.D., Stephen K. Benirschke, M.D.,<br />
<strong>and</strong> M. Bradford Henly, M.D., M.B.A.<br />
Surgical Treatment <strong>of</strong> Displaced Femoral Head Fractures .................................................................................... 15<br />
Sean E. Nork, M.D., Timothey B. Rapp, M.D., <strong>and</strong> M.L. Chip Routt, Jr., M.D.<br />
Wound Healing in Open, Displaced Calcaneal Fractures ..................................................................................... 19<br />
Stephen K. Benirschke, M.D., Patricia Ann Kramer, Ph.D., <strong>and</strong> Sean E. Nork, M.D.<br />
Underst<strong>and</strong>ing <strong>and</strong> Preventing Cervical Spine Whiplash from Rear-End Motor Vehicle Collisions ................. 22<br />
Allan F. Tencer, Ph.D., Sohail K. Mirza, M.D., Kevin Bensel, <strong>and</strong> Philippe Huber<br />
Accuracy <strong>and</strong> Reproducibility <strong>of</strong> Step <strong>and</strong> Gap Measurements from Plain Radiographs After Intra-Articular<br />
Fracture <strong>of</strong> the Distal Radius .................................................................................................................................. 25<br />
Wren V. McCallister, M.D., Jeffrey M. Smith, M.D., Jeff Knight, B.S., <strong>and</strong> Thomas E. Trumble, M.D.<br />
Genomic Sequences <strong>and</strong> Expression <strong>of</strong> the RNA Splicing Factors TASR-1 <strong>and</strong> TASR-2 .................................... 27<br />
Jeremiah M. Clinton, B.S., Howard A. Chansky, M.D., A. Zielinska-Kwiatkowska, M.D., Ernest U. Conrad, M.D.,<br />
<strong>and</strong> Liu Yang, Ph.D.<br />
The Role <strong>of</strong> Fusion Protein-Induced Alternative Splicing In The Development <strong>of</strong> Ewing’s Sarcoma ................ 30<br />
David D. Odell, B.S., Howard A. Chansky, M.D., A. Zielinska-Kwiatkowska, M.D., <strong>and</strong> Liu Yang, Ph.D.<br />
Using a Freeze Fixation Technique <strong>and</strong> Histological Crimp Analysis for Mapping the Strain in Functionally<br />
Loaded Ligaments.................................................................................................................................................... 32<br />
Richard Boorman, M.D., M.Sc., Tony Norman, B.S.E., Frederick A. Matsen III, M.D.,<br />
<strong>and</strong> John Clark, M.D., Ph.D.<br />
The Quality <strong>of</strong> Life Outcomes Following Total Shoulder Arthroplasty are Comparable to Those <strong>of</strong> Total Hip<br />
Arthroplasty <strong>and</strong> Coronary Artery Bypass Grafting .............................................................................................. 35<br />
Richard S. Boorman, M.D., M.Sc., Branko Kopjar, M.D., Ph.D., Edward Fehringer, M.D., R. Sean Churchill, M.D.,<br />
Kevin L. Smith, M.D., <strong>and</strong> Frederick A. Matsen III, M.D.<br />
Less is More: Building Bigger <strong>Bone</strong>s With Less Exercise ....................................................................................... 38<br />
Sundar Srinivasan, Ph.D., David E. Weimer, Steven C. Agans, Steven D. Bain, <strong>and</strong> Ted S. Gross, Ph.D.
Evidence that FGF-18 is a Growth Factor for Mature Human Articular Chondrocytes ..................................... 40<br />
Russell J. Fern<strong>and</strong>es, Ph.D., Jeff L. Ellsworth, Ph.D., Emma E. Morre, Ph.D., Steven D. Hughes, Ph.D.,<br />
<strong>and</strong> David R. Eyre, Ph.D.<br />
A Newly Identified Site <strong>of</strong> Cross-Linking Between Collagens IX <strong>and</strong> II: Insights on Molecular Assembly in<br />
Cartilage ................................................................................................................................................................... 43<br />
Jiann-Jiu Wu, Ph.D., Terri A. Pietka, B.S., Mary Ann Weis, B.S., <strong>and</strong> David R. Eyre, Ph.D.<br />
Reproductive Hormone Effects on ACL Strength .................................................................................................. 45<br />
Emma Woodhouse, M.D., Peter T. Simonian, M.D., Allan F. Tencer, Ph.D., <strong>and</strong> Phil Huber, M.D.<br />
Back Pain in Intercollegiate Rowers ........................................................................................................................ 47<br />
Carol C. Teitz, M.D., John O’Kane, M.D., Bonnie K. Lind, M.S., <strong>and</strong> Jo A. Hannafin, M.D., Ph.D.<br />
Moving Toward Knowledge Building Communities in Health Information Website Design............................. 50<br />
Tracey Wagner, Jennifer Turns, Kristen Shuyler, <strong>and</strong> Aaron Louie<br />
Optimizing the Intrinsic Stability <strong>of</strong> the Glenoid Fossa With Non-Prosthetic Glenoid Arthroplasty ............... 53<br />
Edward J. Weldon, M.D., Richard S. Boorman, M.D., M.Sc., Kevin L. Smith, M.D.,<br />
<strong>and</strong> Frederick A. Matsen III, M.D.<br />
Department <strong>of</strong> Orthopaedics <strong>and</strong> Sports Medicine Faculty ................................................................................. 57<br />
Department Addresses ............................................................................................................................................ 58<br />
Graduating Residents .............................................................................................................................................. 59<br />
Incoming Residents ................................................................................................................................................. 60<br />
New Faculty ............................................................................................................................................................. 61<br />
Research Grants ....................................................................................................................................................... 62<br />
Contributors to Departmental Research <strong>and</strong> Education ....................................................................................... 67<br />
Alumni ..................................................................................................................................................................... 69<br />
Endowments ............................................................................................................................................................ 71
Foreword<br />
At 4 PM on Monday, April 26,<br />
1937 a lone Heinkel 51 bombed<br />
the town square, the Julian<br />
Hotel <strong>and</strong> the rail station <strong>of</strong> Guernica<br />
in Basque Spain. This event is the most<br />
remembered event <strong>of</strong> the Spanish Civil<br />
War between the Republicans <strong>and</strong> the<br />
Nationalists. The Republican<br />
government <strong>of</strong> Spain had granted<br />
autonomy to the Basques. Guernica was<br />
the capital city <strong>of</strong> the independent<br />
republic <strong>and</strong> a symbol <strong>of</strong> freedom. To<br />
teach the Republicans a lesson, the<br />
Spanish Nationalist comm<strong>and</strong>er,<br />
General Emilio Mola, under orders <strong>of</strong><br />
fascist Francisco Franco, invited the<br />
Condor Legion <strong>of</strong> the German<br />
Luftwaffe to use the small city for<br />
incendiary bomb target practice. The<br />
bombing prompted Picasso to begin<br />
painting his greatest masterpiece...<br />
“Guernica”… a prophetic vision <strong>of</strong> the<br />
Second World War.<br />
The gored <strong>and</strong> speared horse recalls<br />
the Spanish Republic, the bull (Franco)<br />
lording over the bereaved, shrieking<br />
woman with her dead child, all <strong>of</strong> which<br />
contrast with the symbols <strong>of</strong> peace: the<br />
broken sword, the solitary flower, <strong>and</strong><br />
the dove. “Guernica” is now an<br />
international icon for peace <strong>and</strong> the<br />
most important work <strong>of</strong> art <strong>of</strong> the<br />
twentieth century.<br />
Picasso’s war casualties, with their<br />
protruding tongues, rolling eyes,<br />
splayed toes <strong>and</strong> necks arched in<br />
spasms, are similar to those persons<br />
presenting today to emergency rooms<br />
seeking our help. Like the central figure<br />
at the top <strong>of</strong> the painting who extends<br />
a lamp, we seek to shed light <strong>and</strong><br />
warmth to those in need. The figure to<br />
the lower right, like our students <strong>and</strong><br />
residents, is drawn to this lamp. The<br />
newsprint across the horse’s body<br />
recalls the importance <strong>of</strong> publishing<br />
findings so that others may share in the<br />
benefit from clinical <strong>and</strong> basic research.<br />
You may see other connections between<br />
the depiction <strong>of</strong> tragedy <strong>and</strong> our efforts<br />
to <strong>of</strong>fset its effects. As Picasso himself<br />
said, “It isn’t up to the painter to define<br />
the symbols. Otherwise it would be<br />
better if he wrote them out in so many<br />
words! The public who look at the<br />
picture must interpret the symbols as<br />
they underst<strong>and</strong> them.” If you want to<br />
see Picasso’s masterwork in person, you<br />
must visit the Museo Nacional Centro<br />
de Arte Reina S<strong>of</strong>ía in Madrid to which<br />
museum it was moved from New York’s<br />
Museum <strong>of</strong> Modern Art only after the<br />
death <strong>of</strong> Franco.<br />
Investigating <strong>and</strong> treating injuries,<br />
arthritis, tumors <strong>and</strong> degenerative<br />
conditions <strong>of</strong> the musculoskeletal<br />
system is the domain <strong>of</strong> the orthopaedic<br />
specialist. Whether working in the lab<br />
or in the operating room, specialists<br />
focus their energy <strong>and</strong> scholarship on<br />
a sharply defined problem, much as a<br />
magnifying glass focuses the energy <strong>of</strong><br />
the sun on a single spot on a piece <strong>of</strong><br />
paper. When I first heard former<br />
Academy President Jim Strickl<strong>and</strong><br />
speak on the power <strong>of</strong> specialization<br />
using the story <strong>of</strong> his father, the shooter,<br />
as a metaphor, I could not resist asking<br />
him if I could reproduce his lecture. We<br />
are honored to have Jim’s <strong>and</strong> his sister<br />
Jill’s permission to share this story <strong>of</strong><br />
specialization with you here.<br />
In this issue <strong>of</strong> our Research Report<br />
we include many examples <strong>of</strong> the power<br />
<strong>of</strong> specialization – the resident honing<br />
interest toward a subspecialty, the<br />
fellow securing the skills to succeed in<br />
academic orthopaedics, <strong>and</strong> the faculty<br />
member making substantial<br />
contributions in a highly specialized<br />
domain to the knowledge which forms<br />
the basis on which Orthopaedics <strong>and</strong><br />
Sports Medicine is based. These<br />
contributions range from the genetics<br />
<strong>of</strong> musculoskeletal tumors, through the<br />
biology <strong>of</strong> connective tissues, the<br />
influence <strong>of</strong> hormones <strong>and</strong> mechanical<br />
loading on bone <strong>and</strong> ligaments, sportsrelated<br />
conditions, the management <strong>of</strong><br />
fractures so that disability is minimized,<br />
<strong>and</strong> finally to the way information can<br />
be developed by knowledge-building<br />
communities <strong>and</strong> shared the world<br />
round.<br />
One <strong>of</strong> the sentinel events for our<br />
Department this year was the<br />
completion <strong>of</strong> the Lynn T. Staheli<br />
Endowed Chair for Pediatric<br />
Orthopaedics. Dr. Staheli was the first<br />
full-time faculty member at Children’s<br />
Hospital –a true specialist. He remains<br />
one <strong>of</strong> the quintessential observers <strong>of</strong><br />
the growth <strong>and</strong> development <strong>of</strong> the<br />
child, reassuring countless parents that<br />
most “flat” feet <strong>and</strong> “bowed” legs in<br />
children are completely normal. This<br />
endowed chair, established through the<br />
generosity <strong>of</strong> many <strong>and</strong> under the<br />
guidance <strong>of</strong> Dr. Lana Staheli, will be a<br />
permanent source <strong>of</strong> academic venture<br />
capital for the faculty at Children’s,<br />
providing resources essential to<br />
exploring better treatment for<br />
childhood deformities, injuries, <strong>and</strong><br />
tumors.<br />
The type <strong>of</strong> support that made the<br />
Staheli Chair possible is essential to the<br />
growth <strong>and</strong> development <strong>of</strong> our<br />
Department. In times when resources<br />
from patient care, the State <strong>of</strong><br />
<strong>Washington</strong>, <strong>and</strong> the federal<br />
government are on the wane, our<br />
growing excellence is increasingly<br />
dependent on endowed support from<br />
you our friends, patients, industrial<br />
partners <strong>and</strong> alumni. We are<br />
succeeding, thanks to you.<br />
U.S. News <strong>and</strong> World Report lists<br />
both our services at Harborview <strong>and</strong> at<br />
<strong>University</strong> <strong>of</strong> <strong>Washington</strong> Medical<br />
Center, in the top ten programs in the<br />
United States (http://<br />
www.usnews.com/usnews/nycu/<br />
health/hosptl/specorth.htm). The<br />
National Institutes <strong>of</strong> Health lists our<br />
Department in the top four <strong>of</strong> all<br />
orthopaedic departments in terms <strong>of</strong><br />
NIH grants awarded for excellence <strong>of</strong><br />
research (http://silk.nih.gov/public/<br />
cbz2zoz.@www.rank01.medrnk.htm).<br />
Combined with the fact that we are the<br />
only academic orthopaedic program<br />
for 25% <strong>of</strong> the l<strong>and</strong>mass <strong>of</strong> the U.S. (the<br />
states <strong>of</strong> <strong>Washington</strong>, Wyoming,<br />
Montana, Alaska <strong>and</strong> Idaho) <strong>and</strong> host<br />
to one <strong>of</strong> the most outst<strong>and</strong>ing<br />
residency <strong>and</strong> fellowship programs,<br />
ours is a special team indeed.<br />
To all <strong>of</strong> you who generously<br />
support excellence in care, teaching,<br />
<strong>and</strong> research at the <strong>University</strong> <strong>of</strong><br />
<strong>Washington</strong> Department <strong>of</strong><br />
Orthopaedics <strong>and</strong> Sports Medicine,<br />
thank you!<br />
Best wishes,<br />
Frederick A. Matsen III, M.D.<br />
Residency Alumnus, 1975<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 1
My Dad The Shooter - A Case For Specialization<br />
JAMES W. STRICKLAND, M.D.<br />
My dad could really shoot the<br />
basketball. He developed his<br />
skills in the small town <strong>of</strong><br />
Owensville Indiana (pop. 450) where<br />
growing boys had little else to do but<br />
play basketball. Dad’s father was an old<br />
time country doctor who was<br />
frequently called away to tend to the<br />
sick, make house calls or deliver babies.<br />
As a result dad had alot <strong>of</strong> time alone<br />
<strong>and</strong> he spent it like many rural Indiana<br />
boys did; shooting baskets. He spent<br />
countless solitary hours in his back yard<br />
on a wide dirt patch where the grass had<br />
been worn away by the constant impact<br />
<strong>of</strong> basketballs <strong>and</strong> tennis shoes. At the<br />
back <strong>of</strong> the patch was a basketball goal<br />
not unlike thous<strong>and</strong>s <strong>of</strong> others which<br />
could be seen throughout the Indiana<br />
countryside <strong>and</strong> from which numerous<br />
wonderful Hoosier players have been<br />
spawned over the years. The goal, which<br />
his father had erected for him, consisted<br />
<strong>of</strong> a wooden backboard with a black<br />
metal rim <strong>and</strong> a ragged grey net<br />
supported by, a stout, rusted metal pipe<br />
firmly anchored in the ground with<br />
concrete. Dad’s unchanging routine<br />
consisted <strong>of</strong> monotonously dribbling a<br />
worn leather ball out to a variety <strong>of</strong><br />
positions well away from the goal; he<br />
would then turn, square himself with<br />
the basket <strong>and</strong> shoot the classic<br />
two-h<strong>and</strong>ed set shot that would<br />
become his trade mark. He would then<br />
follow the ball to the basket, retrieve it<br />
<strong>and</strong> shoot again. This sequence would<br />
be repeated time after time until my<br />
gr<strong>and</strong>mother would call him in or it<br />
became too dark for him to continue.<br />
These private shooting practices were<br />
a year around ritual. Occasionally he<br />
would be joined by other boys <strong>and</strong> they<br />
would go to another goal around town<br />
or the high school gymnasium where<br />
they would play pick-up games. But, for<br />
the most part, it was a lonely self<br />
discipline <strong>and</strong> it produced a very good<br />
shooter.<br />
For a small town, the Owensville<br />
boys basketball team was pretty<br />
competitive <strong>and</strong> dad was easily their<br />
best player. He was big boned, about six<br />
feet tall by his Junior year <strong>and</strong> he<br />
quickly learned to use his height <strong>and</strong><br />
weight to his advantage. He possessed<br />
an innate underst<strong>and</strong>ing <strong>of</strong> the game,<br />
was an intense competitor <strong>and</strong>, above<br />
all, he became a deadly shooter from<br />
almost any position on the court. From<br />
1924 until 1926 Owensville won a lot<br />
<strong>of</strong> games. They beat the big Evansville<br />
teams on a regular basis, won their<br />
sectional tournament two out <strong>of</strong> three<br />
years <strong>and</strong> almost never lost in the<br />
confines <strong>of</strong> their own gym; which,<br />
incidentally, is believed to have had the<br />
first glass backboards in the state <strong>of</strong><br />
Indiana. The gym also had a well<br />
localized dead spot on the basketball<br />
floor <strong>and</strong> the members <strong>of</strong> the team<br />
learned to entice opposing players to<br />
dribble over the spot during crucial<br />
moments <strong>of</strong> a game. When the ball<br />
failed to return to the dribbler’s h<strong>and</strong><br />
the anticipating defensive player would<br />
scoop it up <strong>and</strong> proceed unmolested for<br />
a basket.<br />
From Owensville, dad went 100<br />
miles northeast to Indiana <strong>University</strong><br />
where he played for Everett Dean <strong>and</strong><br />
with Indiana legend Branch<br />
McCracken. He led the team in scoring<br />
his junior years <strong>and</strong> was selected as<br />
Indiana’s second All-American (third<br />
team, College Humor Magazine) in<br />
1929. As a Senior, his playing time was<br />
restricted to a half <strong>of</strong> each game by a<br />
physician who thought he detected a<br />
heart murmur. Throughout his college<br />
career dad’s shooting ability was the<br />
predominate feature <strong>of</strong> his game. It was<br />
described in at least one national sports<br />
publication as the classic, perfect form,<br />
underh<strong>and</strong>ed set shot.<br />
After college, dad went to New York<br />
City where he played for five years at<br />
what was then the mecca <strong>of</strong> U.S.<br />
amateur sports, the New York Athletic<br />
Club. During those years he taught <strong>and</strong><br />
coached underprivileged boys at a<br />
church <strong>and</strong> played pr<strong>of</strong>essional<br />
basketball in upstate New York under<br />
the name Stricklevitch in order to make<br />
some money <strong>and</strong> preserve his amateur<br />
status. When mother, announced that<br />
I was on the way in 1935, dad decided<br />
that they should return home to<br />
Indianapolis to settle down <strong>and</strong> raise a<br />
family. Dad would not play organized<br />
basketball again, but that shot; that<br />
glorious shot, became famous in every<br />
neighborhood we ever lived in.<br />
No basketball player today, at any<br />
level, shoots the ball the way players did<br />
back then. I truly believe, that dad’s<br />
form was absolutely text book for the<br />
two-h<strong>and</strong>ed shot. He was a big man for<br />
that time at six feet one <strong>and</strong> he weighed<br />
210 pounds. His h<strong>and</strong>s were fairly large<br />
but he could barely palm the laced<br />
leather basketballs <strong>of</strong> his period.<br />
Perhaps the key to the shot was the way<br />
he positioned his h<strong>and</strong>s on the ball. His<br />
fingers were spread to maximum<br />
separation <strong>and</strong> placed on each side <strong>of</strong><br />
the ball with his thumbs pointed<br />
straight upward <strong>and</strong> his fingers aligned<br />
directly out from his body. The shot was<br />
started just above the waist <strong>and</strong> about<br />
six inches out from his body with the<br />
wrists straight ahead. He would initiate<br />
the shot by pulling his arms back<br />
slightly at the shoulder <strong>and</strong> rotating his<br />
h<strong>and</strong>s so that his fingers were pointing<br />
downward <strong>and</strong> his thumbs were<br />
pointing out towards the basket. This<br />
motion was quickly reversed as his arms<br />
thrust forward at the shoulder <strong>and</strong> his<br />
wrists snapped upward. His h<strong>and</strong>s were<br />
well past their original position with his<br />
thumbs pointed towards his body at the<br />
time <strong>of</strong> release. This rolling movement<br />
resulted in a tremendous amount <strong>of</strong><br />
backspin; more, I believe, than most<br />
players today achieve with their<br />
one-h<strong>and</strong>ed shots. The trajectory <strong>and</strong><br />
direction <strong>of</strong> dad’s shot was rarely<br />
inaccurate <strong>and</strong> he would only miss if<br />
the shot was a bit long or short. Even<br />
then, the s<strong>of</strong>tness <strong>of</strong> the<br />
semi-underh<strong>and</strong>ed delivery <strong>and</strong> the<br />
reversed spin that he created would<br />
<strong>of</strong>ten hold the ball to the rim where,<br />
after a bounce or two, it would almost<br />
always fall through. He could hit that<br />
shot with deadly accuracy from five to<br />
thirty feet from the basket with only<br />
slight variation in his basic form. Free<br />
throws were almost automatic <strong>and</strong>,<br />
after he retired from active competition,<br />
he could st<strong>and</strong> at any free-throw line<br />
<strong>and</strong> hit shot after shot with the ball<br />
rarely touching the rim.<br />
From 1941 until 1946, dad was the<br />
Indiana Director <strong>of</strong> the Office <strong>of</strong> Price<br />
Administration (OPA) <strong>and</strong> was<br />
subsequently asked to run for Governor<br />
2 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
<strong>of</strong> the state. He respectfully declined the<br />
<strong>of</strong>fer to remain in public service <strong>and</strong>,<br />
in 1946, he started an automobile<br />
dealership which he successful<br />
managed until his retirement in 1982.<br />
Along the way he was the Indiana state<br />
h<strong>and</strong>ball champion for five years, an<br />
excellent squash player <strong>and</strong> a low<br />
h<strong>and</strong>icap golfer. Spinal stenosis<br />
ultimately decreased the function <strong>of</strong> his<br />
legs <strong>and</strong> dad was forced to become<br />
sedentary during the last 15 years <strong>of</strong> his<br />
life. But, his interest in sports <strong>and</strong><br />
particularly basketball never waned. He<br />
remained an extremely close friend <strong>of</strong><br />
his old teammate Branch McCracken,<br />
the legendary Indiana <strong>University</strong> coach,<br />
until Branch died, <strong>and</strong>, although he was<br />
slow to warm up to Bobby<br />
Knight, the two became good<br />
friends <strong>and</strong> occasionally<br />
reminisced on the history <strong>of</strong><br />
basketball <strong>and</strong> the great<br />
coaches <strong>and</strong> players <strong>of</strong> the<br />
past.<br />
Dad was very careful not to<br />
push me into basketball <strong>and</strong><br />
we didn’t have a goal in our<br />
back yard until I ask for one at<br />
age nine. He <strong>and</strong> some friends<br />
personally erected a post,<br />
backboard <strong>and</strong> goal in a dirt<br />
<strong>and</strong> grass field behind our<br />
house <strong>and</strong> for the next six<br />
years that dusty court became<br />
the center <strong>of</strong> neighborhood<br />
activity. Guys (<strong>and</strong> some girls)<br />
<strong>of</strong> all ages would come over<br />
after school <strong>and</strong> on weekends<br />
<strong>and</strong> we would play until dark.<br />
The big event <strong>of</strong> many sessions<br />
would occur whenever we<br />
could get dad out to the court to put<br />
on one <strong>of</strong> his remarkable shooting<br />
exhibitions. After he would make<br />
anywhere from twenty to forty or more<br />
consecutive free-throws, he would<br />
move out to the back fence which my<br />
memory tells me must have been about<br />
forty feet from the basket. It would<br />
usually take him several shots to get the<br />
range following which he would<br />
invariably sink his patented<br />
two-h<strong>and</strong>er. After that, we could usually<br />
coax him to go over the fence <strong>and</strong> into<br />
the alley where he would take a position<br />
up to sixty feet from the basket. Several<br />
<strong>of</strong> us would relay the ball to him <strong>and</strong><br />
sooner or later he would put it through.<br />
Sometimes, when it was getting dark,<br />
you couldn’t even see where he was<br />
shooting from, the ball would just come<br />
flying through the, sky <strong>and</strong> rip through<br />
the nets. A great cheer would erupt <strong>and</strong><br />
dad would emerge from the alley, climb<br />
the fence <strong>and</strong> call it quits having<br />
astonished all my neighborhood<br />
buddies <strong>and</strong> left his son with incredible<br />
pride.<br />
During the forties <strong>and</strong> early fifties,<br />
there was a recreational area not too far<br />
from our home called Little America.<br />
It had a golf driving range, miniature<br />
golf, archery, badminton <strong>and</strong> a number<br />
<strong>of</strong> other diversions. Most important to<br />
our family were the two basketball goals<br />
which they had located near their<br />
entrance. For a quarter you could get<br />
five free-throws <strong>and</strong>, if you made all<br />
five, they would award you a free pass<br />
to any activity on the premises. Several<br />
nights a week, my sister, brother <strong>and</strong> I<br />
would warm dad up in the back yard,<br />
drive to Little America <strong>and</strong>, within ten<br />
minutes we would have all the free<br />
passes we needed to go play. The outlay<br />
for the passes was rarely greater than a<br />
dollar <strong>and</strong> a half <strong>and</strong> our savings over<br />
the usual admission prices was<br />
considerable. I can’t remember him<br />
ever letting us down. After several years,<br />
the management <strong>of</strong> the recreation park<br />
got tired <strong>of</strong> providing our family with<br />
free entertainment, <strong>and</strong> declared that<br />
dad was a pr<strong>of</strong>essional; ineligible to<br />
shoot for free passes. I remember the<br />
night that they cut him <strong>of</strong>f. As a final<br />
sportsmanlike gesture, they h<strong>and</strong>ed<br />
him the ball <strong>and</strong> ask him to make as<br />
many free-throws as he could. He hit<br />
24 straight, missed, <strong>and</strong> then hit his next<br />
48. None <strong>of</strong> us contested their decision<br />
to censor dad.<br />
Dad’s performance at the 1948<br />
Indiana State Fair st<strong>and</strong>s right at the top<br />
<strong>of</strong> my list <strong>of</strong> all-time great athletic<br />
performances under pressure. I was<br />
twelve years old <strong>and</strong> convinced that dad<br />
was the best basketball shooter in the<br />
world. I had been taken to the fair by<br />
the family <strong>of</strong> a friend <strong>and</strong> had seen<br />
several basketball shooting concessions<br />
near the midway. One, in particular,<br />
caught my eye. It had four rows <strong>of</strong><br />
prizes ranging from cheap trinkets on<br />
the lowest row, to stuffed toys on the<br />
second <strong>and</strong> third rows, culminating in<br />
a br<strong>and</strong> new Hutch leather basketball<br />
on the top row. For<br />
twenty-five cents you got<br />
three shots <strong>and</strong>, if you hit<br />
them all, you had the option<br />
<strong>of</strong> quitting <strong>and</strong> taking a prize<br />
from the lowest row or<br />
receiving three more shots in<br />
an effort to move to the<br />
second row <strong>of</strong> prizes: <strong>and</strong> so<br />
on. It would take twelve<br />
straight baskets to win the<br />
ball, which, I deeply coveted.<br />
I couldn’t wait to get dad to<br />
the fair. After all I’d seen him<br />
make more than twelve shots<br />
in a row on numerous<br />
occasions. There was no<br />
question in my mind that he<br />
could do it.<br />
I described the situation<br />
to dad at dinner that night<br />
<strong>and</strong> we struck a deal that I<br />
would back him <strong>and</strong> when<br />
(not if) he won, the<br />
basketball would be mine. On the<br />
following day, we warmed up for a<br />
while on our goal in the back yard <strong>and</strong><br />
headed for the fair. I brought along a<br />
gr<strong>and</strong> total <strong>of</strong> fifty cents to finance dad’s<br />
efforts realizing that there was an<br />
outside chance that he might miss a<br />
shot on his first try. That he might miss<br />
twice was unthinkable. In my mind that<br />
beautiful Hutch ball was already my<br />
property.<br />
At the fair, I grabbed dad’s h<strong>and</strong> <strong>and</strong><br />
pulled him directly to the<br />
predetermined concession. Dad looked<br />
the game over <strong>and</strong> immediately<br />
recognized many problems that had<br />
gone totally unnoticed by my young,<br />
simplistic mind. The shot was not a<br />
routine free-throw. The goals (there<br />
were two) were at least twelve feet high,<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 3
the rims were much smaller than<br />
regulation <strong>and</strong> they were tilted<br />
asymmetrically. The ball return was<br />
facilitated by netting which extended<br />
from the underside <strong>of</strong> the backboards<br />
to a rail at the shooting platform. That<br />
rail was high enough that the shot had<br />
to be taken from at least eighteen feet<br />
away from the basket. Finally the balls<br />
were rubber, worn smooth <strong>and</strong> very<br />
warped. The two balls which were in use<br />
at the concession were dissimilar in<br />
weight <strong>and</strong> configuration <strong>and</strong> the sleazy<br />
guy who was running the game<br />
alternately interchanged the balls to<br />
each shooter to keep him from<br />
becoming familiar with any single ball.<br />
In short, the game was very heavily<br />
stacked against the shooter. The<br />
possibility <strong>of</strong> anyone, at any level,<br />
hitting three straight, let alone twelve<br />
in a row, was remote.<br />
Prior to dad’s chance to shoot, we<br />
watched four or five other fruitless<br />
contestants pay their money, miss all<br />
their shots, complain about the unfair<br />
conditions <strong>and</strong> leave. Finally, dad’s time<br />
came <strong>and</strong>, after I proudly stepped up<br />
<strong>and</strong> paid the entry fee <strong>of</strong> twenty-five<br />
cents, he stepped up on the platform.<br />
For a short time he moved the ball<br />
around between his large h<strong>and</strong>s looking<br />
for the best way to hold the warped orb.<br />
He then took several practice throws<br />
without releasing the ball <strong>and</strong> found<br />
that he would have to st<strong>and</strong> back a little<br />
farther to shoot his low-release shot. He<br />
lifted the ball above his head <strong>and</strong><br />
shrugged his shoulders to remove any<br />
tension. Finally, he was ready.<br />
I watched with confident<br />
expectation as the familiar rolling<br />
motion sent the first shot toward the<br />
high, tilted basket. It rattled around the<br />
rim <strong>and</strong> , aided by the strong backspin,<br />
dropped through. The next two shots<br />
were perfect <strong>and</strong>, when asked if we<br />
wanted to accept a prize from the lowest<br />
row or go on, there was never a<br />
hesitation. The next three shots went<br />
through without touching the rim.<br />
Same decision. Shot seven was perfect<br />
<strong>and</strong>, then, much to my disbelief <strong>and</strong><br />
horror, he missed. Dad turned <strong>and</strong><br />
looked at me with an expression <strong>of</strong><br />
disappointment. “Sorry Chum,” he said.<br />
“Hey pop,” I replied “don’t worry<br />
about it. I’ve got another twenty-five<br />
cents.” With that, I gave the sleazy<br />
proprietor my last quarter, patted my<br />
dad on the back <strong>and</strong> returned to my<br />
spot behind the platform. By then there<br />
was quite a crowd around the<br />
concession; much to the delight <strong>of</strong> the<br />
ball man who was quite certain that his<br />
expensive top prize was safe. In<br />
retrospect the crowd, which would<br />
cheer his every shot, must have added<br />
considerably to the already formidable<br />
pressure on dad.<br />
Again he began his machinery-like<br />
shooting motion. Three, six, nine in a<br />
row. At each level I simply nodded to<br />
the man that dad wished to keep on<br />
shooting. Ten, eleven: As I remember it<br />
they were all perfect. The eleventh<br />
basket brought a tremendous cheer<br />
from the now considerable gallery.<br />
Then, there was a hush. The concession<br />
man dropped the ball at dad’s feet in<br />
an effort to break his concentration.<br />
Dad picked it up without changing<br />
expressions, looked for the best place<br />
to place his h<strong>and</strong>s, took a deep breath<br />
<strong>and</strong> sent, it on its way. The only sound<br />
was that <strong>of</strong> the ball settling in the center<br />
<strong>of</strong> the nets. There was a tumultuous<br />
cheer by those behind us. I leaped to<br />
the platform to hug dad <strong>and</strong> together<br />
we accepted the basketball from the top<br />
row. The ball-man conceded that it was<br />
the only ball he’d lost that year.<br />
I don’t think I appreciated how great<br />
my dad’s state fair performance was for<br />
many years. He’s gone now <strong>and</strong> it<br />
remains as a treasured memory. My dad<br />
could really shoot the basketball!<br />
4 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Visiting Lecturers<br />
Robert A. Winquist, M.D.<br />
This year at our annual LeCocq<br />
Lecture on January 24 <strong>and</strong> 25,<br />
we were most honored to have<br />
one <strong>of</strong> our fellow alumnus as our<br />
lecturer - Dr. Robert Winquist. Dr.<br />
Winquist was one <strong>of</strong> our Department<br />
<strong>of</strong> Orthopaedics <strong>and</strong> Sports Medicine’s<br />
graduating residents in 1974 <strong>and</strong> after<br />
a six month fellowship in Switzerl<strong>and</strong><br />
<strong>and</strong> Germany, he joined the faculty <strong>of</strong><br />
the Department <strong>of</strong> Orthopaedics as an<br />
Assistant Pr<strong>of</strong>essor <strong>and</strong> later was<br />
promoted to Associate Pr<strong>of</strong>essor. He<br />
currently is a Clinical Pr<strong>of</strong>essor <strong>of</strong><br />
Orthopaedics Surgery at the <strong>University</strong><br />
<strong>of</strong> <strong>Washington</strong> <strong>and</strong> practices at Swedish<br />
Hospital <strong>and</strong> Medical Center where he<br />
has been the Chief <strong>of</strong> Orthopaedics. Dr.<br />
Winquist’s work in the field <strong>of</strong><br />
traumaotolgy is well known <strong>and</strong> he is<br />
well sought after to be a visiting<br />
pr<strong>of</strong>essor at many <strong>of</strong> the universities<br />
throughout the world. Thus, it was a<br />
special treat to have him accept our<br />
invitation to be this year’s LeCocq<br />
Lecturer. The faculty, residents, <strong>and</strong><br />
community physicians were treated to<br />
3 innovating lectures from Dr.<br />
Winquist: “Intramedullary Nailing <strong>of</strong><br />
the Femur,” “Design Implant: A Toy<br />
Story,” <strong>and</strong> “Intramedullary Nailing <strong>of</strong><br />
the Tibia.”<br />
Joseph Buckwalter, M.D.<br />
This year at our annual Residents’<br />
Research Days on May 16 <strong>and</strong><br />
17, we were honored to have Dr.<br />
Joseph Buckwalter, Pr<strong>of</strong>essor <strong>and</strong> Head<br />
<strong>of</strong> the Department <strong>of</strong> Orthopaedic<br />
Surgery at the <strong>University</strong> <strong>of</strong> Iowa<br />
Hospitals <strong>and</strong> Clinics, return to be our<br />
OREF Hark Lecturer. Dr. Buckwalter<br />
was our OREF Hark Lecturer in 1992<br />
<strong>and</strong> due to the overwhelming response<br />
from the residents to have him back, we<br />
were delighted when he accepted our<br />
invitation to return this year. Dr.<br />
Buckwalter earned his bachelor’s degree<br />
in psychology in 1969 <strong>and</strong> a master’s<br />
degree in pathology in 1972. He earned<br />
his medical degree in 1974 <strong>and</strong><br />
completed his orthopaedic residency at<br />
the <strong>University</strong> <strong>of</strong> Iowa Hospitals <strong>and</strong><br />
Clinics. Ever since he has served as a<br />
faculty member at the <strong>University</strong> <strong>of</strong><br />
Iowa Hospitals <strong>and</strong> Clinics with the<br />
exception <strong>of</strong> serving as a Visiting<br />
Pr<strong>of</strong>essor at the <strong>University</strong> <strong>of</strong> Bern in<br />
Switzerl<strong>and</strong> in 1991. During the 2 days<br />
<strong>of</strong> lectures, the faculty, residents, <strong>and</strong><br />
community physicians were treated to<br />
3 lectures from Dr. Buckwalter: “Aging<br />
<strong>and</strong> Osteoarthritis,” “Ankle<br />
Osteoarthritis – Unique Characteristics<br />
<strong>and</strong> Treatment,” <strong>and</strong> “Orthopaedics in<br />
2020.” In addition to Dr. Buckwalter’s<br />
lectures, the R3’s <strong>and</strong> the R4’s presented<br />
the progress <strong>of</strong> their research, while the<br />
R5’s presented the completion <strong>of</strong> their<br />
research projects.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 5
Lynn T. Staheli, M.D.<br />
<strong>2002</strong> Distinguished Alumnus<br />
<strong>University</strong> <strong>of</strong> <strong>Washington</strong> School <strong>of</strong> Medicine<br />
Dr. Lynn Staheli is one <strong>of</strong><br />
the pioneers who<br />
established the current<br />
Pediatric Orthopedic Society in 1975<br />
<strong>and</strong> is a past president <strong>of</strong> the society.<br />
He founded the Journal <strong>of</strong> Pediatric<br />
Orthopedics 22 years ago <strong>and</strong> remains<br />
an active co-editor. An author <strong>of</strong> 85<br />
original articles, 10 book chapters, <strong>and</strong><br />
8 books, Lynn continues to contribute<br />
to the scientific foundation <strong>of</strong> pediatric<br />
orthopedics <strong>and</strong> to disseminate that<br />
information to the world through his<br />
writings <strong>and</strong> lectures. He produces his<br />
books through desktop publishing to<br />
keep costs down so that the books can<br />
be purchased in developing countries.<br />
As a guest speaker in more than 25<br />
countries, he is aware <strong>of</strong> the financial<br />
challenge that those physicians face in<br />
affording our very expensive books. As<br />
well, Dr. Staheli has just been awarded<br />
the Distinguished Achievement Award<br />
for a lifetime <strong>of</strong> excellent work in<br />
pediatric orthopaedics by the Pediatric<br />
Orthopaedic Society <strong>of</strong> North America.<br />
Most clinical research in<br />
orthopedics involves the<br />
demonstration that one operation is<br />
more effective or safer than another, or<br />
that surgery is more effective than<br />
nonoperative treatment. Lynn has<br />
published the results <strong>of</strong> such research,<br />
many <strong>of</strong> which have become l<strong>and</strong>mark<br />
studies. He developed the “Staheli” shelf<br />
acetabular augmentation procedure<br />
that has become an international<br />
st<strong>and</strong>ard in the surgical<br />
armamentarium for hip dysplasia.<br />
But his most significant<br />
contributions have been those that have<br />
shown that no surgery <strong>and</strong>, in fact, no<br />
treatment are better than surgery or<br />
sham treatment in certain conditions.<br />
Among those l<strong>and</strong>mark studies are<br />
ones demonstrating that flatfeet are a<br />
normal foot shape in children, that<br />
toeing in <strong>and</strong> toeing out are normal<br />
limb alignments in children, <strong>and</strong> that<br />
most children develop an arch <strong>and</strong><br />
change their in-toeing <strong>and</strong> out-toeing<br />
through normal growth <strong>and</strong><br />
development. As a function <strong>of</strong> this<br />
extensive body <strong>of</strong> work, he is the<br />
ultimate child advocate, using research<br />
<strong>and</strong> teaching to provide evidence-based<br />
care to his patients <strong>and</strong> to train others<br />
to do the same. He’s not done. He has<br />
more questions to answer, more “right<br />
answers” to question, <strong>and</strong> more<br />
information to disseminate.<br />
Congratulations to Lynn <strong>and</strong> to all<br />
those who generously made this Chiar<br />
possible.<br />
6 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Is the Absence <strong>of</strong> an Ipsilateral Fibular Fracture Predictive <strong>of</strong><br />
Tibial Pilon Fracture Severity<br />
DAVID P. BAREI, M.D., F.R.C.S.(C), SEAN E. NORK, M.D., CARLO BELLABARBA, M.D,<br />
AND BRUCE J. SANGEORZAN, M.D.<br />
The management <strong>of</strong> tibial pilon<br />
fractures remains controversial<br />
<strong>and</strong> challenging. Axial-loading,<br />
particularly from motor vehicle<br />
collisions or falls from significant<br />
heights, is a common mechanism <strong>of</strong><br />
injury. Principles <strong>of</strong> operative<br />
treatment include reconstruction <strong>of</strong> the<br />
distal tibial articular surface followed<br />
by restoration <strong>of</strong> mechanical axes.<br />
Anatomic reduction <strong>of</strong> the articular<br />
surface along with stable fixation<br />
allowing early motion has been shown<br />
to be the most important predictor <strong>of</strong><br />
satisfactory outcome, <strong>and</strong> should be<br />
prioritized. The ability to obtain<br />
anatomic reduction with stable<br />
fixation, however, decreases with<br />
increasing comminution <strong>of</strong> the<br />
articular surface.<br />
Fibular fractures are commonly<br />
associated with tibial pilon injuries,<br />
particularly those caused by shearingtype<br />
mechanisms. Other fracture<br />
patterns, however, do not demonstrate<br />
this associated feature. The absence <strong>of</strong><br />
an ipsilateral fibular fracture in patients<br />
with tibial pilon injuries may predict a<br />
more severe injury pattern to the tibial<br />
plafond. Presumably, the injurious<br />
energy is completely absorbed by the<br />
tibial plafond resulting in more severe<br />
epiphyseal <strong>and</strong> metaphyseal injury,<br />
precluding accurate reduction <strong>and</strong><br />
worse outcomes. Further, the<br />
deleterious effects <strong>of</strong> mechanical<br />
impact at the chondrocyte level may<br />
also lead to joint degeneration despite<br />
an accurate reduction. The purpose <strong>of</strong><br />
this study is to evaluate the difference<br />
in the radiographic severity <strong>of</strong> tibial<br />
plafond injuries with fibular fractures<br />
as compared to those without fibular<br />
fractures.<br />
MATERIALS AND METHODS<br />
Between January 1997 <strong>and</strong> February<br />
2000, 20 consecutive tibial pilon<br />
injuries without associated fibular<br />
fractures were retrospectively identified<br />
using a prospectively gathered trauma<br />
database. Over the same time period,<br />
an age <strong>and</strong> gender matched cohort <strong>of</strong><br />
20 tibial pilon injuries with fibular<br />
fractures were r<strong>and</strong>omly selected. A<br />
computer-based image editing s<strong>of</strong>tware<br />
program was used to digitize <strong>and</strong><br />
conceal the fibula on the initial<br />
anteroposterior (AP) <strong>and</strong> lateral<br />
radiographs on all 40 injuries. Care was<br />
taken to completely eliminate any<br />
fibular fracture, <strong>and</strong> associated fibular<br />
malalignment, on both the AP <strong>and</strong><br />
lateral views. Every effort was made to<br />
minimize concealment <strong>of</strong> the tibial<br />
plafond while maximizing the<br />
concealment <strong>of</strong> the fibula. Radiographs<br />
were then independently rank ordered<br />
(1 = least severe, 40 = most severe) by<br />
three orthopaedic traumatologists<br />
according to the severity <strong>of</strong> tibial<br />
plafond injury. Observers ranked all<br />
fractures taking into consideration all<br />
the radiographic factors they believe are<br />
important in the assessment <strong>of</strong> tibial<br />
pilon fracture severity. The observers<br />
were not given any specific guidelines<br />
regarding ranking, but relied on their<br />
significant clinical experience in<br />
managing these fractures. Injuries were<br />
also classified according to AO/OTA<br />
guidelines, which assigns fractures an<br />
alpha-numeric code according to body<br />
region <strong>and</strong> fracture location. Fractures<br />
affecting the metaphyseal <strong>and</strong><br />
epiphyseal portions are divided into A,<br />
B, or C-type groupings, indicating an<br />
extra-articular fracture, partial articular<br />
fracture, or complete articular fracture,<br />
respectively. The premise is that the<br />
increasing alpha assignment indicates<br />
a more severe fracture pattern, <strong>and</strong><br />
ultimately a worse prognosis.<br />
RESULTS<br />
Inter-observer agreement was<br />
assessed using the weighted Kappa<br />
statistic (k=0.6). Mean rank scores for<br />
pilon injuries with fibula fractures was<br />
24.4 while those without fibula<br />
fractures was 16.7 (T-test = 0.02). Rank<br />
order was repeated for only AO/OTA<br />
C-type pilon injuries <strong>and</strong> demonstrated<br />
a mean <strong>of</strong> 10.3 for those with fibular<br />
fractures <strong>and</strong> 8.7 for those without<br />
fibular fracture (T-test = 0.5). Mean<br />
rank order for AO/OTA B-type injuries<br />
was 11.1 whereas the mean rank order<br />
for C-type injuries was 24.5 (T-test =<br />
0.001). The proportion <strong>of</strong> fibula<br />
fractures in B-type versus C-type pilon<br />
injuries was assessed using the Chisquare<br />
statistic (p = 0.006).<br />
DISCUSSION<br />
Operative treatment <strong>of</strong> tibial pilon<br />
fractures is controversial. Evidence<br />
suggests that increasing comminution<br />
leads to a worse result for a variety <strong>of</strong><br />
reasons. Identifying factors that are<br />
associated with a given outcome aid in<br />
clinical decision making. It has been<br />
theorized that the absence <strong>of</strong> fibular<br />
fractures in association with ipsilateral<br />
tibial pilon injuries may be associated<br />
with a poor outcome. Two different<br />
potential scenarios are suggested: the<br />
first is that the injurious energy is <strong>of</strong><br />
lower magnitude <strong>and</strong> is insufficient to<br />
injure the fibula, or conversely, the<br />
energy is significant but is completely<br />
absorbed by the tibial plafond. To<br />
evaluate this theory, we used the rank<br />
order technique with experienced<br />
traumatologists blinded to the presence<br />
or absence <strong>of</strong> a fibular injury, who then<br />
independently assessed the<br />
radiographic severity <strong>of</strong> the tibial pilon<br />
fracture. The kappa statistic<br />
demonstrated satisfactory correlation,<br />
consistent with other published<br />
material on interobserver reliability <strong>of</strong><br />
the AO/OTA fracture classification<br />
system. This study demonstrates that,<br />
overall, tibial pilon injuries with fibular<br />
fractures are more severe than those<br />
without fibular fractures. Complete<br />
articular (C-type) injuries, with or<br />
without fibular fractures, are equally<br />
severe. Supporting the OTA<br />
classification, C-type injuries were<br />
consistently ranked as significantly<br />
more severe than B-type injuries. The<br />
presence <strong>of</strong> a fibular fracture was more<br />
frequently associated with C-type<br />
injury than B-type. This data suggests<br />
that the presence <strong>of</strong> an intact fibula in<br />
not predictive <strong>of</strong> a more severe injury<br />
to the tibial pilon, but is predictive <strong>of</strong> a<br />
less severe, B-type, injury.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 7
(A)<br />
(A)<br />
(B)<br />
(B)<br />
Figure 1: Representative example <strong>of</strong> a type 43<br />
C3 distal tibial articular fracture with an<br />
associated fibular fracture.<br />
Figure 2: Representative example <strong>of</strong> a type 43<br />
C3 distal tibial articular fracure with an intact<br />
fibula. Note the significant shortening <strong>and</strong> joint<br />
impaction.<br />
RECOMMENDED READING<br />
Swiontkowski, M.F.; S<strong>and</strong>s, A.K.; Agel,<br />
J.; Diab, M.; Schwappach, J.R.; Kreder,<br />
H.J.: Interobserver variation in the AO/<br />
OTA fracture classification system for<br />
pilon fractures: is there a problem J<br />
Orthop Trauma, 11(7): 467-470., 1997.<br />
Martin, J.S.; Marsh, J.L.; Bonar, Susan<br />
K.; et al.: Assessment <strong>of</strong> the AO/ASIF<br />
fracture classification for the distal tibia.<br />
J Orthop Trauma, 11(7): 477-483.,<br />
1997.<br />
Kellam, J.F.; Waddell, J.P.: Fractures <strong>of</strong><br />
the distal tibial metaphysis with intraarticular<br />
extension – the distal tibial<br />
explosion fracture. J Trauma, 19: 593-<br />
601., 1979.<br />
Sirkin, M.; S<strong>and</strong>ers, R.; DiPasquale, T,;<br />
Herscovici, D.: A staged protocol for<br />
s<strong>of</strong>t tissue management in the<br />
treatment <strong>of</strong> complex pilon fractures.<br />
J Orthop Trauma, 13(2): 78-84., 1999.<br />
Decoster, T.A.; Willis, M.C.; Marsh, J.L.;<br />
et al.: Rank order analysis <strong>of</strong> tibial<br />
plafond fractures: does injury or<br />
reduction predict outcome Foot Ankle<br />
Int, 20(1): 44-9., 1999.<br />
8 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Intramedullary Nailing <strong>of</strong> Fractures <strong>of</strong> the Proximal<br />
One-Quarter Tibia<br />
SEAN E. NORK, M.D., DAVID P. BAREI, M.D., F.R.C.S.(C), JASON L. SCHRICK, B.S., SARAH K. HOLT, B.S.,<br />
AND BRUCE J. SANGEORZAN, M.D.<br />
Treatment <strong>of</strong> proximal tibial<br />
metaphyseal fractures remains<br />
problematic. Techniques<br />
include external fixation, plate fixation,<br />
<strong>and</strong> intramedullary nailing.<br />
Intramedullary nailing <strong>of</strong> proximal<br />
third tibial fractures has been associated<br />
with malalignment, nonunion, <strong>and</strong> the<br />
need for revision fixation. Previous<br />
reports suggest malalignment <strong>of</strong> 58%<br />
to 84% <strong>of</strong> patients. The purpose <strong>of</strong> this<br />
paper is to report the technique <strong>and</strong><br />
results <strong>of</strong> intramedullary nailing <strong>of</strong><br />
tibial fractures involving the proximal<br />
25%.<br />
MATERIALS AND METHODS<br />
Over a 36 months period, 456<br />
patients with fractures <strong>of</strong> the tibial shaft<br />
(OTA type 42) or proximal tibial<br />
metaphysis (OTA type 41A2 <strong>and</strong> A3)<br />
were treated operatively at a level one<br />
trauma center. Forty-two <strong>of</strong> these<br />
fractures involved or extended into the<br />
proximal 25% <strong>of</strong> the tibia. Three<br />
fractures were treated with plates <strong>and</strong><br />
two fractures were treated with external<br />
fixation based on the preference <strong>of</strong> the<br />
attending orthopaedic surgeon. The<br />
remaining thirty-seven fractures in<br />
thirty-five patients were treated<br />
primarily with intramedullary nailing<br />
<strong>of</strong> their proximal quarter tibial fractures<br />
<strong>and</strong> formed the study group. Thirteen<br />
fractures were open. There were 28<br />
male <strong>and</strong> 7 female patients, ranging in<br />
age from 19 to 73 years (mean 42 years).<br />
All radiographs were evaluated by two<br />
orthopaedic traumatologists <strong>and</strong> the<br />
following variables were measured:<br />
total tibial length, proximal extent <strong>of</strong><br />
the fracture, fracture classification,<br />
healing, preoperative, postoperative,<br />
<strong>and</strong> final alignment <strong>and</strong> reduction in<br />
two planes. An angular malreduction<br />
was defined as greater than 5 degrees<br />
in any plane. Three fractures had<br />
proximal intraarticular extensions.<br />
Twenty-two fractures had segmental<br />
comminution.<br />
All patients were treated with<br />
reamed intramedullary nailing with the<br />
patient positioned supine <strong>and</strong> the knee<br />
flexed over a radiolucent wedge pillow.<br />
Techniques employed to facilitate<br />
maintenance <strong>of</strong> reduction included<br />
intraoperative use <strong>of</strong> a femoral<br />
distractor, a proximal <strong>and</strong> lateral<br />
starting point, <strong>and</strong> percutaneous clamp<br />
placement. In order to improve control<br />
<strong>of</strong> the proximal segment in difficult<br />
fracture patterns, thirteen patients<br />
underwent plate application in addition<br />
to intramedullary nailing. In three<br />
cases, these plate were removed<br />
intraoperatively after nail passage while<br />
in the other ten, the plates were left in<br />
place. Lag screw fixation was used to<br />
augment the fixation in an additional<br />
three patients.<br />
RESULTS<br />
These fractures extended<br />
proximally to an average <strong>of</strong> 17% <strong>of</strong> the<br />
tibial length (range, 4% to 25%). The<br />
average distance from the proximal<br />
articular surface to the fracture was 67.8<br />
mm (range, 17 mm to 102 mm). The<br />
average tibial length was 397 mm<br />
(range, 353 mm to 449 mm).<br />
Angulation was within five degrees in<br />
all planes in 36 <strong>of</strong> 37 fractures (97.3%).<br />
One patient had an angular<br />
malreduction <strong>of</strong> seven degrees <strong>of</strong> varus.<br />
Postoperative angulation (average<br />
varus 0.4, valgus 0.3, flexion 0.2,<br />
recurvatum 0.2 degrees) as well as the<br />
the final angulation (average varus 0.4,<br />
valgus 0.4, flexion 0.3, recurvatum 0.3<br />
degrees) were acceptable. No secondary<br />
procedures were required to achieve<br />
union.<br />
DISCUSSION<br />
Intramedullary nailing <strong>of</strong>fers an<br />
attractive alternative with proximal<br />
metaphyseal tibial fractures. Early<br />
reports reflected a poor underst<strong>and</strong>ing<br />
<strong>of</strong> tibial anatomy <strong>and</strong> the behavior <strong>of</strong><br />
the proximal segment. This resulted in<br />
a high incidence <strong>of</strong> valgus <strong>and</strong> flexion<br />
malalignment with associated posterior<br />
translation <strong>of</strong> the distal segment.<br />
Recommendations have included<br />
avoidance <strong>of</strong> medullary implants in<br />
proximal third tibial fractures despite<br />
the biomechanical advantages <strong>of</strong> this<br />
technique.<br />
These procedures were performed<br />
by orthopaedic traumatologists<br />
experienced with medullary nailing <strong>and</strong><br />
knowledgeable about the pitfalls with<br />
proximal tibial fractures. The need for<br />
additional techniques to accomplish<br />
placement <strong>of</strong> a medullary device in a<br />
reduced fracture was quite common. A<br />
proximal <strong>and</strong> lateral starting point<br />
helps ensure placement <strong>of</strong> the nail<br />
accurately down the medullary canal.<br />
The most common adjuvant technique<br />
in our patients was temporary or<br />
permanent short plate fixations (35%)<br />
placed extraperiosteally to control the<br />
proximal fracture with nail passage.<br />
These plates can be placed through a<br />
separate posteromedial or anterolateral<br />
incision in closed fractures, <strong>and</strong> care<br />
should be taken to avoid further s<strong>of</strong>t<br />
tissue stripping from the bone. In open<br />
fractures, the traumatic laceration can<br />
be incorporated into a surgical<br />
exposure that extends the skin incision<br />
yet doesn’t further disrupt the osseus<br />
s<strong>of</strong>t tissue attachments <strong>of</strong> the tibia. Loss<br />
<strong>of</strong> reduction did not occur <strong>and</strong> healing<br />
progressed despite additional fixations.<br />
Complications were uncommon.<br />
In our series <strong>of</strong> patients, the<br />
articular extension was addressed prior<br />
to intramedullary nailing <strong>of</strong> the tibia.<br />
This was performed to prevent<br />
additional displacement <strong>and</strong> to assist in<br />
reduction <strong>of</strong> the proximal fragment.<br />
Loss <strong>of</strong> reduction <strong>of</strong> the articular<br />
segment was not seen with nail<br />
insertions. Strategic placement <strong>of</strong><br />
periarticular lag screws may help<br />
prevent this potential complication.<br />
Articular fractures healed without loss<br />
<strong>of</strong> reduction in our series.<br />
CONCLUSIONS<br />
Despite the reported experience <strong>of</strong><br />
others with a substantial incidence <strong>of</strong><br />
malalignment, our experience reveals<br />
that in experienced h<strong>and</strong>s,<br />
intramedullary nailing <strong>of</strong> proximal<br />
tibial fractures is a safe <strong>and</strong> effective<br />
technique. Alignment can be well<br />
maintained despite the short segment<br />
<strong>of</strong> the proximal tibia. Simple articular<br />
fractures <strong>and</strong> extensions are not a<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 9
Figure 1: AP <strong>and</strong> lateral radiographs <strong>of</strong> a<br />
classic proximal quarter tibial fracture with<br />
segmental comminution (AO/OTA type<br />
41A3) in a patient who was struck by an<br />
automobile. This injury was open <strong>and</strong><br />
associated with a compartmental<br />
syndrome.<br />
Figure 2: Post operative radiographs after<br />
intramedullary nailing. The open wounds were<br />
used intraoperatively to allow for fracture<br />
reduction during reaming <strong>and</strong> nail passage.<br />
Figure 3: Post operative radiographs <strong>of</strong> a<br />
proximal quarter tibial fracture (AO/OTA type<br />
42A) treated with short plate fixation <strong>and</strong><br />
reamed intramedullary nailing.<br />
10 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
contraindication to intramedullary<br />
fixation. Short plate fixations to<br />
maintain this difficult reduction, either<br />
temporary or permanent, were effective<br />
<strong>and</strong> not associated with complications.<br />
RECOMMENDED READING<br />
Bono, C. M.; Levine, R. G.; Rao, J. P.;<br />
<strong>and</strong> Behrens, F. F.: Nonarticular<br />
proximal tibia fractures: treatment<br />
options <strong>and</strong> decision making. J Am<br />
Acad Orthop Surg, 9(3):176-86., 2001.<br />
Buehler, K. C.; Green, J.; Woll, T. S.; <strong>and</strong><br />
Duwelius, P. J.: A technique for<br />
intramedullary nailing <strong>of</strong> proximal<br />
third tibia fractures. J Orthop Trauma,<br />
11(3):218-23, 1997.<br />
Freedman, E. L., <strong>and</strong> Johnson, E. E.:<br />
Radiographic analysis <strong>of</strong> tibial fracture<br />
malalignment<br />
following<br />
intramedullary nailing. Clin Orthop,<br />
315(315):25-33, 1995.<br />
Lang, G. J.; Cohen, B. E.; Bosse, M. J.;<br />
<strong>and</strong> Kellam, J. F.: Proximal third tibial<br />
shaft fractures. Should they be nailed<br />
Clin Orthop, 315(315):64-74, 1995.<br />
Ricci, W. M.; O’Boyle, M.; Borrelli, J.;<br />
Bellabarba, C.; <strong>and</strong> S<strong>and</strong>ers, R.:<br />
Fractures <strong>of</strong> the proximal third <strong>of</strong> the<br />
tibial shaft treated with intramedullary<br />
nails <strong>and</strong> blocking screws. J Orthop<br />
Trauma, 15(4):264-70., 2001.<br />
.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 11
Complications Associated With Internal Fixation <strong>of</strong><br />
Comminuted, Bicondylar Tibial Plateau Fractures<br />
DAVID P. BAREI, M.D., F.R.C.S.(C), SEAN E. NORK, M.D., WILLIAM J. MILLS, M.D.,<br />
STEPHEN K. BENIRSCHKE, M.D., AND M. BRADFORD HENLEY, M.D., M.B.A.<br />
Complex bicondylar tibial<br />
plateau fractures are highenergy<br />
injuries that <strong>of</strong>ten occur<br />
in polytraumatized patients. Articular<br />
depression, sagittal <strong>and</strong> coronal plane<br />
condylar separation, <strong>and</strong> detachment <strong>of</strong><br />
the metaphysis from the diaphysis are<br />
defining fracture characteristics.<br />
Marked swelling, abrasions,<br />
compartmental syndrome, <strong>and</strong> open<br />
wounds commonly occur. Treatment<br />
goals include accurate articular<br />
reconstruction, restoration <strong>of</strong> knee<br />
stability, reestablishment <strong>of</strong> condylar<br />
width, maintenance <strong>of</strong> the normal<br />
mechanical axis, <strong>and</strong> stable fixation.<br />
Treatment techniques include isolated<br />
lateral plating, small wire external<br />
fixation with or without limited<br />
internal fixation, lateral plating<br />
combined with medial external<br />
fixation, <strong>and</strong> double plating.<br />
Unfortunately, medial <strong>and</strong> lateral<br />
plating, particularly through a single<br />
anterior incision, has been associated<br />
with high wound complications <strong>and</strong><br />
deep sepsis. Double plating through<br />
separate medial <strong>and</strong> lateral incisions<br />
may minimize anteromedial s<strong>of</strong>t tissue<br />
dissection <strong>and</strong> decrease significant<br />
wound complications. The purpose <strong>of</strong><br />
this study is to report the complications<br />
<strong>and</strong> infection rate associated with<br />
double plating complex tibial plateau<br />
fractures stabilized through two<br />
incisions.<br />
MATERIALS AND METHODS<br />
Over a 79 month period, all patients<br />
sustaining an intra-articular fracture <strong>of</strong><br />
the proximal tibia were collected from<br />
a prospectively designed orthopaedic<br />
database <strong>and</strong> reviewed retrospectively.<br />
This search identified 308 patients with<br />
319 bicondylar tibial plateau fractures.<br />
Ten fractures were misclassified, leaving<br />
309 fractures eligible for review. One<br />
hundred <strong>and</strong> seventy-eight fractures<br />
had simple articular involvement (AO/<br />
OTA type 41-C1 <strong>and</strong> 41-C2) <strong>and</strong> were<br />
excluded. Thirteen fractures were<br />
treated with primary amputation, five<br />
were treated non-operatively, two were<br />
treated with staged arthroplasty, 13<br />
fractures were excluded for various<br />
reasons, <strong>and</strong> 8 fractures with<br />
insufficient data for review were also<br />
excluded. The remaining 90 patients<br />
sustained 90 complex tibial plateau<br />
fractures (AO/OTA type 41-C3) <strong>and</strong><br />
formed the study group. All 90 patients<br />
were treated with plate fixation through<br />
two operative approaches. The use <strong>of</strong><br />
a single midline anterior surgical<br />
approach was ab<strong>and</strong>oned prior to the<br />
study period.<br />
There were 57 male <strong>and</strong> 33 female<br />
patients with a mean age <strong>of</strong> 44.03 years<br />
(range, 21 to 88 years). Twelve fractures<br />
were open (13.3%) <strong>and</strong> classified as<br />
type II (1 patient), type IIIA (8<br />
patients), type IIIB (2 patients), <strong>and</strong><br />
type IIIC (1 patient). Compartmental<br />
syndrome was diagnosed <strong>and</strong> treated<br />
with fasciotomies in 12 patients<br />
(13.3%). Temporary anterior spanning<br />
external fixation was performed in 45<br />
patients (50%) secondary to the<br />
severity <strong>of</strong> the local s<strong>of</strong>t tissue injury<br />
or associated life-threatening injuries.<br />
The average interval from injury to<br />
definitive surgical treatment was 8.98<br />
days (range, 0 - 40 days).<br />
Technique<br />
Medial column fixation through a<br />
posteromedial approach is typically<br />
performed first. The incision is placed<br />
approximately one centimeter posterior<br />
to the posteromedial edge <strong>of</strong> the tibial<br />
metaphysis, then parallels the sartorius<br />
<strong>and</strong> pes tendons proximally.<br />
Subperiosteal dissection is limited to<br />
the fracture edges <strong>and</strong> anticipated plate<br />
position. Disruption <strong>of</strong> the s<strong>of</strong>t tissues<br />
on the anteromedial aspect <strong>of</strong> the tibia<br />
is avoided. The posteromedial plateau<br />
<strong>and</strong> metaphyseal fracture components<br />
are reduced, provisionally held, <strong>and</strong><br />
stabilized with a posteromedial plate.<br />
Lateral column fixation is<br />
performed using a st<strong>and</strong>ard<br />
anterolateral approach. A longitudinal<br />
skin incision is made one centimeter<br />
lateral to the tibial crest curving laterally<br />
over Gerdy’s tubercle <strong>and</strong> extending<br />
proximally in a longitudinal fashion to<br />
the lateral femoral epicondyle. The<br />
iliotibial b<strong>and</strong> is incised in line with the<br />
skin incision <strong>and</strong> mobilized from<br />
Gerdy’s tubercle. A sub-meniscal<br />
arthrotomy is performed followed by<br />
provisional articular <strong>and</strong> metadiaphyseal<br />
reconstruction.<br />
Subchondral defects are bone grafted.<br />
Buttress plate fixation <strong>of</strong> the lateral<br />
column is performed with the proximal<br />
screws strategically placed to support<br />
articular comminution. Supervised<br />
knee motion is started when the<br />
incisions are secure. Patients remain<br />
non-weightbearing for a minimum <strong>of</strong><br />
twelve weeks.<br />
RESULTS<br />
Non-Septic Complications<br />
Non-septic complications included<br />
one nonunion at the proximal tibial<br />
meta-diaphysis requiring bone grafting<br />
<strong>and</strong> revision plating. Thirteen patients,<br />
exclusive <strong>of</strong> those with infections,<br />
required delayed (greater than six<br />
months from injury) implant removal<br />
for relief <strong>of</strong> local symptoms. Two <strong>of</strong><br />
these patients also underwent resection<br />
<strong>of</strong> heterotopic ossification to improve<br />
knee motion. Six patients required a<br />
knee manipulation for extension<br />
contracture, <strong>and</strong> one patient<br />
underwent tendo-Achilles lengthening<br />
for an equinus contracture. Seventeen<br />
patients incurred significant deep<br />
venous thromboses (DVT). No patient<br />
was diagnosed with pulmonary<br />
embolism. There were no deaths.<br />
Septic Complications<br />
Deep wound infections occurred in<br />
seven patients (7.78%), two <strong>of</strong> which<br />
were associated with septic arthritis.<br />
Two <strong>of</strong> the seven infections occurred in<br />
patients who sustained open injuries.<br />
One patient declined surgical or<br />
medical management <strong>of</strong> his infection.<br />
The remaining six patients had clinical<br />
resolution after an average <strong>of</strong> 4<br />
additional procedures (range 1 to 7<br />
procedures) combined with antibiotic<br />
therapy.<br />
Two patients sustained vascular<br />
injuries <strong>and</strong> were treated with vascular<br />
reconstruction <strong>and</strong> prophylactic<br />
fasciotomy. The presence <strong>of</strong> an open<br />
injury, compartmental syndrome, the<br />
12 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Figure 1: Injury radiographs <strong>and</strong> CT scans<br />
<strong>of</strong> a 44 year old male after a high energy<br />
accident. The sagittal CT is centered at the<br />
medial plateau <strong>and</strong> demonstrates the<br />
coronal fracture line with separation <strong>of</strong> the<br />
posteromedial plateau.<br />
use <strong>of</strong> temporary spanning external<br />
fixation, or surgical timing was not<br />
found to be associated with the<br />
occurrence <strong>of</strong> sepsis with statistical<br />
significance.<br />
Superficial wound complications<br />
occurred in eight patients (8.89%).<br />
One patient required debridement <strong>of</strong><br />
the lateral operative site seven days after<br />
fixation for persistent serous wound<br />
drainage. The remaining patients were<br />
managed successfully with local wound<br />
care. One person required surgical<br />
debridement for bone graft donor site<br />
sepsis.<br />
DISCUSSION<br />
Management goals for tibial plateau<br />
fractures include re-establishment <strong>of</strong><br />
articular congruity, restoration <strong>of</strong><br />
anatomic <strong>and</strong> mechanical axes, <strong>and</strong><br />
stable fixation to allow early knee range<br />
<strong>of</strong> motion while maintaining fracture<br />
reduction. Extensive dissection<br />
through the injured s<strong>of</strong>t tissue envelope<br />
to achieve reduction <strong>and</strong> apply<br />
stabilizing implants may significantly<br />
increase post-operative infection rates,<br />
hindering long-term successful<br />
outcome. Deep wound infection rates<br />
in patients treated with double plating<br />
have been reported to be as high as<br />
87.5%. Recently, Veri et al., reported a<br />
matched cohort series comparing<br />
internal fixation with ring fixator<br />
methods for high-grade tibial plateau<br />
fractures. These authors found 44% <strong>of</strong><br />
the fractures treated with open<br />
methods had an infection requiring<br />
intravenous antibiotics <strong>and</strong>/or<br />
operative debridement as compared to<br />
12% in the ring fixator group.<br />
The high complication rate<br />
reported with open reduction <strong>and</strong> plate<br />
fixation in complex tibial plateau<br />
fractures has prompted<br />
recommendations for alternative<br />
methods <strong>of</strong> reduction <strong>and</strong> stabilization.<br />
Combined limited internal fixation<br />
with external fixation, hybrid external<br />
fixation, <strong>and</strong> small wire external<br />
fixation <strong>of</strong>fer presumed decreased<br />
wound sepsis rates by minimizing<br />
further s<strong>of</strong>t tissue injury. Marsh<br />
reported on 21 bicondylar tibial plateau<br />
fractures managed with limited internal<br />
fixation <strong>and</strong> medial half-pin external<br />
fixation, with septic arthritis occurring<br />
in two patients (9.5%). Other studies<br />
<strong>of</strong> bicondylar tibial plateau fractures<br />
treated with hybrid external fixation<br />
report infections in 12 to 13% <strong>of</strong><br />
patients.<br />
The ability to obtain an accurate<br />
reduction with indirect means is<br />
difficult <strong>and</strong> radiographic confirmation<br />
can be misleading. Furthermore,<br />
ligamentotaxis techniques are unable to<br />
reduce depressed articular segments<br />
that do not have s<strong>of</strong>t tissue attachments.<br />
Direct articular surface visualization<br />
with open techniques, therefore, may<br />
allow the fractures to be more precisely<br />
reduced. The posteromedial <strong>and</strong><br />
anterolateral incisions allow direct<br />
reduction <strong>and</strong> stabilization <strong>of</strong> their<br />
respectively displaced articular surfaces.<br />
A plate <strong>and</strong> screw construct that<br />
buttresses the split fracture<br />
components while providing a “raft” <strong>of</strong><br />
screws to support elevated articular<br />
segments is preferred. The two surgical<br />
approaches are intended to minimize<br />
injury to the tenuous s<strong>of</strong>t tissue<br />
envelope on the anteromedial aspect <strong>of</strong><br />
the proximal tibia. This area <strong>of</strong>ten<br />
sustains severe injury at the time <strong>of</strong> the<br />
fracture, <strong>and</strong> an extensive midline<br />
anterior approach may further<br />
jeopardize its viability.<br />
Deep wound infections occurred in<br />
7 <strong>of</strong> the 90 patients that formed this<br />
study group (7.78%). Two <strong>of</strong> these<br />
patients also had septic involvement <strong>of</strong><br />
the knee joint (2.2%). Because <strong>of</strong> the<br />
low incidence <strong>of</strong> infection, no<br />
consistent co-factors could be singled<br />
out as risk factors with statistical<br />
significance. Clinical resolution was<br />
obtained in the six patients who agreed<br />
to surgical <strong>and</strong> medical management.<br />
This report reviews the wound<br />
complication rates associated with<br />
medial <strong>and</strong> lateral plating using a two<br />
incision approach in a homogeneous<br />
population <strong>of</strong> high-energy tibial<br />
plateau fractures. Accordingly, these<br />
injuries can be successfully treated with<br />
the double plating technique described.<br />
The deep infection rate <strong>of</strong> 7.78%<br />
remains significant with this procedure,<br />
but responds well to surgical <strong>and</strong><br />
medical management, <strong>and</strong> is similar to<br />
those rates reported in studies<br />
advocating indirect reduction <strong>and</strong><br />
external fixation methods. The deep<br />
infection rate using the two-incision<br />
approach is also substantially lower<br />
than previous studies reporting results<br />
<strong>of</strong> open reduction <strong>and</strong> plate fixation.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 13
Figure 2: Postoperative radiographs demonstrating reconstruction <strong>of</strong> the articular surface.<br />
RECOMMENDED READING<br />
Benirschke, S. K. Agnew, S. G. Mayo, K.<br />
A. Santoro, V. M., <strong>and</strong> Henley, M. B.:<br />
Immediate internal fixation <strong>of</strong> open,<br />
complex tibial plateau fractures:<br />
treatment by a st<strong>and</strong>ard protocol. J<br />
Orthop Trauma, 6: 78-86, 1992.<br />
Georgiadis, G. M.: Combined anterior<br />
<strong>and</strong> posterior approaches for complex<br />
tibial plateau fractures. J <strong>Bone</strong> <strong>Joint</strong><br />
Surg [Br], 76: 285-289, 1994.<br />
Watson, J. T.: High-energy fractures <strong>of</strong><br />
the tibial plateau. Orthop Clin North<br />
Am, 25: 723-752, 1994.<br />
Young, M. J., <strong>and</strong> Barrack, R. L.:<br />
Complications <strong>of</strong> internal fixation <strong>of</strong><br />
tibial plateau fractures. Orthop Rev, 23:<br />
149-154, 1994.<br />
Marsh, J. L. Smith, S. T., <strong>and</strong> Do, T. T.:<br />
External fixation <strong>and</strong> limited internal<br />
fixation for complex fractures <strong>of</strong> the<br />
tibial plateau. J <strong>Bone</strong> <strong>Joint</strong> Surg [Am],<br />
77: 661-673, 1995.<br />
Veri, J. P. Blachut, P. O’Brien, P., <strong>and</strong><br />
Pirani, S.: High-grade tibial plateau<br />
fractures: A matched cohort study<br />
comparing internal fixation <strong>and</strong> ring<br />
fixator methods. OTA Abstract,<br />
Charlotte, NC, 184, 1999.<br />
14 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Surgical Treatment <strong>of</strong> Displaced Femoral Head Fractures<br />
SEAN E. NORK, M.D., TIMOTHY B. RAPP, M.D., AND M.L. CHIP ROUTT, JR., M.D.<br />
Femoral head fractures are<br />
uncommon injuries associated<br />
with hip dislocations <strong>and</strong><br />
fracture dislocations. Optimal<br />
treatment <strong>of</strong> femoral head fractures<br />
remains poorly defined. Closed<br />
management techniques have been<br />
associated with poor clinical results,<br />
mostly symptomatic postraumatic<br />
arthritis <strong>of</strong> the hip joint. Surgical<br />
treatment may be beneficial, especially<br />
in fractures that involve the weight<br />
bearing area <strong>of</strong> the femoral head.<br />
Complications are related to both the<br />
injury <strong>and</strong> surgical treatment <strong>of</strong><br />
femoral head fractures <strong>and</strong> include<br />
aseptic necrosis, heterotopic<br />
ossification, malreduction, fixation<br />
failure, <strong>and</strong> postraumatic arthritis. The<br />
purpose <strong>of</strong> this study is to evaluate the<br />
operative treatment <strong>of</strong> displaced<br />
femoral head fractures using an<br />
anterior surgical exposure <strong>and</strong><br />
management protocol.<br />
MATERIALS AND METHODS<br />
Over a five year period, 21 patients<br />
with displaced femoral head fractures<br />
were treated surgically at our institution<br />
<strong>and</strong> retrospectively reviewed. All <strong>of</strong> the<br />
patients had posterior hip dislocations.<br />
There were 15 male <strong>and</strong> 6 female<br />
patients, ranging in age from 18 to 58<br />
years (mean 30.9 years). The<br />
mechanisms <strong>of</strong> injury were automobile<br />
accidents in sixteen patients,<br />
motorcycle accidents in three, all terrain<br />
vehicle accident in one, <strong>and</strong> a fall while<br />
snow skiing in another. The left hip was<br />
injured in eleven patients. The patients’<br />
average ISS was 16.8 (range, 9 – 50).<br />
Associated injuries included six patients<br />
with traumatic brain injuries, three<br />
with spinal injuries, <strong>and</strong> ten with other<br />
orthopaedic injuries requiring<br />
operative intervention. One patient had<br />
an ipsilateral sciatic nerve palsy.<br />
Preoperative patient evaluations<br />
included st<strong>and</strong>ard resuscitations,<br />
physical examinations, urgent<br />
attempted closed reductions <strong>of</strong> the<br />
dislocated hip, <strong>and</strong> pelvic<br />
anteroposterior <strong>and</strong> oblique plain<br />
radiographs, <strong>and</strong> two dimensional<br />
pelvic computed tomography (CT)<br />
scans.<br />
The fractures were classified by<br />
location according to Pipkin. The<br />
fractures were suprafoveal in 12<br />
patients, <strong>and</strong> infrafoveal in 9 patients.<br />
There were seven Pipkin type 1<br />
fractures, twelve type 2 fractures, two<br />
type 3 fractures, <strong>and</strong> zero type 4<br />
fractures. Eight patients had peripheral<br />
posterior wall acetabular injuries, but<br />
none required surgical treatment.<br />
Fracture comminution <strong>and</strong> impaction<br />
were noted on the preoperative pelvic<br />
computed tomography scans in 19<br />
patients (90.5%). Intrarticular debris<br />
was identified on the scans in 16<br />
patients (76.2%). The displaced<br />
femoral head fragment remained in the<br />
acetabulum in 17 patients, <strong>and</strong> was<br />
extruded in the other 4 patients.<br />
Our indications for operative<br />
treatment were radiographic: (1)<br />
fragment displacement greater than 3<br />
millimeters, (2) hip joint debris, (3) a<br />
nonconcentric reduction <strong>of</strong> the hip<br />
joint, <strong>and</strong> clinical: (4) obstructed<br />
passive range <strong>of</strong> hip motion under<br />
anesthesia, <strong>and</strong> (5) hip joint instability.<br />
Surgical Treatment Protocol<br />
Each patient was treated according<br />
to a uniform management scheme.<br />
After complete resuscitation <strong>and</strong><br />
evaluation <strong>of</strong> the patient, operative<br />
timing depended on the patient’s<br />
overall medical condition <strong>and</strong> specific<br />
injury pattern. Two patients with<br />
associated femoral neck fractures <strong>and</strong><br />
another with an irreducible fracturedislocation<br />
required emergent<br />
operative intervention.<br />
In the 19 patients without an<br />
associated femoral neck fracture, the<br />
fractures were exposed using a<br />
modification <strong>of</strong> the Smith Peterson<br />
anterior surgical exposure. Fracture<br />
reductions were accomplished after<br />
surgical anterior dislocations <strong>of</strong> the<br />
hips.<br />
Postoperatively, intravenous<br />
cephalosporin antibiotics were<br />
administered until the drains were<br />
discontinued according to their<br />
outputs. Postoperative duplex vascular<br />
evaluations screened for venous<br />
thrombosis <strong>of</strong> the lower extremities <strong>and</strong><br />
were documented. Immediate<br />
postoperative pelvic plain radiographs<br />
<strong>and</strong> CT scans were obtained. Ectopic<br />
bone prophylaxis was not used.<br />
No orthoses were used. In all<br />
patients, hip flexion was restricted to<br />
less than 60 degrees for 6 weeks after<br />
surgery. If their overall condition<br />
allowed, protected partial weight<br />
bearing <strong>of</strong> the injured hip was<br />
progressed over 12 weeks after surgery.<br />
Postoperative clinical <strong>and</strong> radiographic<br />
examinations occurred at the six <strong>and</strong><br />
twelve weeks intervals, <strong>and</strong> annually<br />
thereafter.<br />
RESULTS<br />
Nineteen patients were available for<br />
follow up averaging 27.3 months<br />
postoperatively (range, 8 – 78 months).<br />
Two patients had uncomplicated early<br />
radiographic <strong>and</strong> clinical follow-up<br />
limited to three months.<br />
Eleven patients were treated with<br />
reduction <strong>and</strong> internal fixation. In the<br />
eleven patients treated with internal<br />
fixation, the fracture was suprafoveal in<br />
nine patients, <strong>and</strong> infrafoveal in two<br />
patients. Severe fracture comminution<br />
prevented accurate reduction <strong>and</strong> stable<br />
fracture fixation in the other ten<br />
patients. As opposed to the fixation<br />
group, in these ten patients treated with<br />
fragment excision the femoral head<br />
fracture was suprafoveal in three<br />
patients <strong>and</strong> infrafoveal in seven<br />
patients.<br />
Fixation consisted <strong>of</strong> 1.5 mm <strong>and</strong><br />
2.0 mm cortical lag screws. A total <strong>of</strong><br />
29 screws was used. The number <strong>of</strong><br />
screws per patient ranged from two to<br />
five (mean, 2.6), depending on the<br />
number <strong>and</strong> size <strong>of</strong> the femoral head<br />
fragments. Since the majority <strong>of</strong> the<br />
fragment preparation was<br />
accomplished prior to anterior surgical<br />
hip dislocation, the average<br />
intraoperative anterior dislocation time<br />
for joint debridement <strong>and</strong> internal<br />
fixation was only 12.2 minutes (range<br />
10 - 26 minutes). Of these eleven<br />
fixation patients, ten had anatomical<br />
reductions. In the remaining patient,<br />
the clinical articular fragment<br />
reduction appeared accurate, however<br />
the postoperative computed<br />
tomography scan revealed areas <strong>of</strong><br />
missing cancellous bone between the<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 15
(A)<br />
(B) (C) (D)<br />
(E) (F) (G)<br />
Figure 1: (A) The plain pelvic anteroposterior radiograph in this 27 year old male patient reveals his right hip fracture-dislocation. The femoral head fracture<br />
fragment remains within the joint. The displaced peripheral posterior wall fracture is seen superolaterally. The femoral neck is not fractured. (B) Using<br />
intravenous sedation <strong>and</strong> muscle relaxation, closed manipulative reduction <strong>of</strong> the hip was atraumatic <strong>and</strong> successful. This pelvic computed tomography (CT)<br />
scan axial image demonstrates the peripheral posterior wall acetabular fracture <strong>and</strong> the congruent location <strong>of</strong> the femoral head within the acetabular dome.<br />
(C) This CT axial image reveals the displacement <strong>and</strong> location <strong>of</strong> the femoral head fracture fragment. (D) On the day after injury, the hip joint was irrigated<br />
<strong>and</strong> the femoral head fracture was accurately reduced through an anterior surgical exposure. Stable fixation was achieved with two minifragment intraosseus<br />
lag screws. The hip was stable after femoral head fracture reduction <strong>and</strong> fixation. (E) The postoperative CT scan demonstrates the reduction <strong>and</strong> screws.<br />
(F&G) One year later, he remains asymptomatic. He returned to playing competetive soccer. According to these oblique plain pelvic radiographs, the femoral<br />
head fracture has healed without aseptic necrosis. Class I ectopic bone formation is seen in the region <strong>of</strong> the rectus femoris tendon repair. The posterior wall<br />
fracture healed uneventfully. His hip joint spaces are symmetrical.<br />
16 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
fracture fragments due to<br />
comminution. The peripheral fracture<br />
contact was excellent yet the cancellous<br />
surfaces had gap according to the scan.<br />
This situation was not visible clinically<br />
intraoperatively. He had early loss <strong>of</strong><br />
reduction <strong>and</strong> fixation failure. He<br />
developed symptomatic posttraumatic<br />
hip arthritis <strong>and</strong> required total hip<br />
arthroplasty 36 months after his injury.<br />
After fixation or excision, all 21<br />
patients had intraoperative hip stability<br />
to passive range <strong>of</strong> motion. This<br />
included the eight patients with<br />
peripheral minimally displaced<br />
posterior wall acetabular fractures.<br />
None <strong>of</strong> these eight patients therefore<br />
required reduction <strong>and</strong> fixation <strong>of</strong> their<br />
small acetabular fractures in order to<br />
achieve intraoperative hip stability.<br />
The postoperative plain<br />
radiographs <strong>and</strong> CT scans revealed<br />
concentric hip reductions in all 21<br />
patients. There were no screw related<br />
errors. Each <strong>of</strong> the 29 screws was<br />
subchondral <strong>and</strong> intraosseus in<br />
location. No patient had residual loose<br />
debris according to these CT scans.<br />
Ten patients in the fixation group<br />
demonstrated uneventful fracture<br />
union. The other had early fixation<br />
failure <strong>and</strong> postraumatic arthritis.<br />
Femoral head fracture fragment<br />
necrosis did not occur in the eleven<br />
patients treated with fixation. Similarly,<br />
aseptic necrosis <strong>of</strong> the femoral head did<br />
not occur in either treatment group. All<br />
eight associated posterior wall injuries<br />
healed uneventfully both clinically <strong>and</strong><br />
radiographically. None <strong>of</strong> the patients<br />
demonstrated subsequent hip joint<br />
instability.<br />
Heterotopic ossification developed<br />
in 19 patients (90.5%) with a mean<br />
Brooker Class <strong>of</strong> 1.6. In the patients<br />
treated with internal fixation,<br />
heterotopic ossification was Class 0 in<br />
two, Class I in four, Class II in three,<br />
Class III in one, <strong>and</strong> Class IV in one<br />
(average Brooker Class, 1.7). In the<br />
patients treated with fragment excision,<br />
heterotopic ossification was Class 0 in<br />
two, Class I in three, Class II in four,<br />
Class III in none, <strong>and</strong> Class IV in one<br />
(average Brooker Class, 1.5). The two<br />
patients with Class IV ectopic bone had<br />
functional compromise <strong>and</strong> opted for<br />
excision at five <strong>and</strong> fourteen months.<br />
DISCUSSION<br />
The indications for open reduction<br />
<strong>and</strong> internal fixation <strong>of</strong> femoral head<br />
fractures remain controversial.<br />
Accurate reduction <strong>of</strong> suprafoveal<br />
femoral head fragments is necessary to<br />
help restore the normal peripheral<br />
loading characteristics <strong>and</strong> to decrease<br />
the peak articular cartilage stresses in<br />
the hip. In our series, preoperatively<br />
we planned to fix each fracture,<br />
however two distinct management<br />
patterns occurred. In the fixation group<br />
<strong>of</strong> eleven patients, nine had suprafoveal<br />
fractures. The other two had large<br />
infrafoveal fracture fragments which<br />
allowed stable fixation. Conversely, in<br />
the excision group <strong>of</strong> ten patients, only<br />
three had suprafoveal fractures. These<br />
were severely comminuted preventing<br />
accurate open reduction <strong>and</strong> stable<br />
fixation. Surprisingly, in these three<br />
patients with suprafoveal fractures,<br />
their excisions did not cause hip<br />
instability nor has early postraumatic<br />
arthritis developed.<br />
Femoral head fractures may be<br />
associated with displaced posterior wall<br />
acetabular fractures. Eight patients in<br />
our series had small peripheral<br />
posterior wall avulsion fractures noted<br />
on the injury pelvic CT scan.<br />
Interestingly, after surgical treatment <strong>of</strong><br />
the femoral head fractures in these eight<br />
patients, hip stability was noted <strong>and</strong><br />
they did not require a separate<br />
acetabular operation. Similarly, hip<br />
abduction orthoses were not used<br />
postoperatively in any patients <strong>and</strong><br />
subsequent hip instability did not<br />
occur.<br />
Several authors advocate that the<br />
anterior hip surgical exposure facilitates<br />
reduction <strong>of</strong> irreducible hip fracturedislocations,<br />
identification <strong>of</strong> the<br />
anteromedial femoral head fracture,<br />
access to the acetabulum for removal<br />
<strong>of</strong> loose osteochondral debris, <strong>and</strong><br />
accurate reduction <strong>of</strong> the femoral head<br />
fracture. Our results using a modified<br />
anterior surgical exposure support their<br />
findings. The anterior hip approach<br />
was modified in this series to include<br />
only the distal portion <strong>of</strong> the st<strong>and</strong>ard<br />
Smith-Peterson surgical exposure.<br />
Elevation <strong>of</strong> the origin <strong>of</strong> the tensor<br />
fascia muscle was avoided, possibly<br />
reducing hip abduction <strong>and</strong> flexion<br />
weakness <strong>and</strong> ectopic bone formation.<br />
Similarly, the anterior hip capsulotomy<br />
in our series was fashioned to diminish<br />
the chance <strong>of</strong> capsular vascular injury.<br />
In order to accurately reduce the<br />
femoral head fracture, all <strong>of</strong> the<br />
fragments were removed from the<br />
injury field. Even those fragments with<br />
the ligamentum teres still intact were<br />
removed from the acetabulum by<br />
incising their ligamentum <strong>and</strong> residual<br />
s<strong>of</strong>t tissue attachments. The fragments<br />
were then prepared for reduction <strong>and</strong><br />
fixation on the operating nurse’s sterile<br />
field. Anterior surgical dislocation <strong>of</strong><br />
the proximal femur into the wound<br />
allowed accurate reduction <strong>and</strong><br />
fixation, or excision <strong>of</strong> the femoral head<br />
fracture fragments. Two patients with<br />
associated femoral neck fractures <strong>and</strong><br />
associated infrafoveal femoral head<br />
fractures had Watson-Jones exposures<br />
without anterior hip surgical<br />
dislocation. As a result in both patients,<br />
the femoral head fracture fragments<br />
were able to be excised.<br />
Aseptic necrosis is a potential<br />
complication in any traumatic hip joint<br />
injury. In posterior hip dislocations<br />
without an associated fracture, the<br />
incidence <strong>of</strong> aseptic necrosis has been<br />
reported from 10 to 21.8% . The<br />
combination <strong>of</strong> traumatic posterior hip<br />
fracture-dislocation, anterior surgical<br />
exposure <strong>of</strong> the hip joint with anterior<br />
capsulotomy, removal <strong>of</strong> the femoral<br />
head fracture fragment from the<br />
acetabulum for preparation, <strong>and</strong><br />
surgical dislocation <strong>of</strong> the hip were not<br />
associated with aseptic necrosis <strong>of</strong> the<br />
fracture fragment or femoral head in<br />
our patients.<br />
Few fixation options are available<br />
for femoral head fractures because <strong>of</strong><br />
the fracture fragment size <strong>and</strong> location.<br />
The implants should be located beneath<br />
the articular cartilage surface, yet<br />
provide sufficient fixation to prevent<br />
early failure. In our patients, fixation<br />
was achieved with small implants (1.5<br />
mm <strong>and</strong> 2.0 mm cortical lag screws)<br />
selected according to the fragment size.<br />
Multiple points <strong>of</strong> fixation (average 2.6<br />
per patient) with countersunk screws<br />
allowed for symmetrical compression<br />
<strong>and</strong> stable fixation.<br />
In our series, no difference was seen<br />
in the severity <strong>of</strong> heterotopic<br />
ossification in patients treated with<br />
excision or open reduction. While<br />
ectopic bone was commonly<br />
encountered (81%), clinically<br />
significant bone formation requiring<br />
excision was seen in only two patients,<br />
both <strong>of</strong> whom had closed head injuries.<br />
Given this <strong>and</strong> other series incidences<br />
<strong>of</strong> ectopic bone, we advocate routine<br />
prophylaxis for these patients.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 17
CONCLUSIONS<br />
Femoral head fractures are<br />
associated with posterior hip<br />
dislocations, yet are uncommon<br />
injuries. The displaced fracture<br />
fragment is located anteromedially <strong>and</strong><br />
involves a variable amount <strong>of</strong> the<br />
weight bearing surfaces. Their<br />
successful management remains<br />
controversial. In our series <strong>of</strong> 21<br />
operatively treated patients using a<br />
modified anterior surgical exposure,<br />
eleven had open reduction <strong>and</strong> internal<br />
fixation <strong>of</strong> their femoral head fractures.<br />
Comminution <strong>of</strong> the fracture<br />
fragments precluded internal fixation<br />
in the remaining ten patients. Operative<br />
management <strong>of</strong> these fractures allowed<br />
for anatomic restoration <strong>of</strong> the articular<br />
surface in over 90% <strong>of</strong> the patients.<br />
These fractures are frequently<br />
comminuted <strong>and</strong> associated with<br />
intrarticular osteochondral debris.<br />
Accurate reduction <strong>of</strong> femoral head<br />
fractures is possible in patients without<br />
severe comminution, using an anterior<br />
surgical exposure. It is unnecessary to<br />
elevate the tensor fascia lata from the<br />
outer ilium for exposure. The<br />
obturator oblique radiograph best<br />
demonstrates the injury. Stable fixation<br />
can be accomplished with<br />
minifragment, subchondral,<br />
intraosseus screws. Ectopic bone<br />
formation is common, yet rarely<br />
symptomatic requiring excision.<br />
Despite being avascular, these femoral<br />
head fragments healed, <strong>and</strong> aseptic<br />
necrosis <strong>of</strong> the femoral head did not<br />
occur.<br />
Moed, B. R., <strong>and</strong> Karges, D. E.:<br />
Prophylactic indomethacin for the<br />
prevention <strong>of</strong> heterotopic ossification<br />
after acetabular fracture surgery in<br />
high-risk patients. J Orthop Trauma,<br />
8(1):34-9, 1994.<br />
Pipkin, G.: Treatmnt <strong>of</strong> grade IV<br />
frature-disloation <strong>of</strong> the hip. A review.<br />
J <strong>Bone</strong> <strong>Joint</strong> Surg [Am], 39:1027-1042,<br />
1957.<br />
Routt, M. L. R.; Simonian, P. T.; <strong>and</strong><br />
Hansen, S. T.: Young patients with<br />
femoral head fractures. Master<br />
Techniques in Orthopaedic Surgery.<br />
The Hip. Philadelphia, Lippincott-<br />
Raven, 1998.<br />
Swiontkowski, M. F.; Thorpe, M.; Seiler,<br />
J. G.; <strong>and</strong> Hansen, S. T.: Operative<br />
management <strong>of</strong> displaced femoral head<br />
fractures: case-matched comparison <strong>of</strong><br />
anterior versus posterior approaches<br />
for Pipkin I <strong>and</strong> Pipkin II fractures. J<br />
Orthop Trauma, 6(4):437-42, 1992.<br />
Trueta, J., <strong>and</strong> Harrison, M. H. M.: The<br />
normal vascular anatomy <strong>of</strong> the<br />
femoral head in adult man. J <strong>Bone</strong> <strong>Joint</strong><br />
Surg [Br], 35:442-461, 1953.<br />
RECOMMENDED READING<br />
Brav, E. A.: Traumatic dislocation <strong>of</strong> the<br />
hip. J <strong>Bone</strong> <strong>Joint</strong> Surg [Am], 44:1115-<br />
1134, 1962.<br />
Brumback, R. J.; Kenzora, J. E.; Levitt,<br />
L. E.; Burgess, A. R.; <strong>and</strong> Poka, A.:<br />
Fractures <strong>of</strong> the femoral head. Hip,<br />
27(6):181-206, 1987.<br />
Epstein, H. C.; Wiss, D. A.; <strong>and</strong> Cozen,<br />
L.: Posterior fracture dislocation <strong>of</strong> the<br />
hip with fractures <strong>of</strong> the femoral head.<br />
Clin Orthop, 201(201):9-17, 1985.<br />
Konrath, G. A.; Hamel, A. J.; Guerin, J.;<br />
Olson, S. A.; Bay, B.; <strong>and</strong> Sharkey, N.<br />
A.: Biomechanical evaluation <strong>of</strong><br />
impaction fractures <strong>of</strong> the femoral<br />
head. J Orthop Trauma, 13(6):407-13,<br />
1999.<br />
18 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Wound Healing in Open, Displaced Calcaneal Fractures<br />
STEPHEN K. BENIRSCHKE, M.D., PATRICIA ANN KRAMER, PH.D., AND SEAN E. NORK, M.D.<br />
Recent reports in the orthopaedic<br />
literature have indicated that a<br />
substantial number <strong>of</strong><br />
complications occur following open<br />
reduction <strong>and</strong> internal fixation (ORIF)<br />
<strong>of</strong> calcaneal fractures, even when a<br />
lateral approach is used. In one report<br />
that included 63 feet, 12 feet (19%)<br />
developed deep dehiscences requiring<br />
inpatient care. Another report <strong>of</strong> 190<br />
patients treated with ORIF via a lateral<br />
approach found that 40 (21%)<br />
developed wound complications that<br />
required surgical intervention. Wound<br />
healing complications in open calcaneal<br />
fractures is much more <strong>of</strong> a pervasive<br />
problem than in closed fractures. In<br />
one study <strong>of</strong> 43 open calcaneal fractures<br />
treated over an 8 year study period, the<br />
overall infection rate was 37% <strong>and</strong><br />
osteomyelitis developed in 19% <strong>of</strong> all<br />
fractures. The infection rate for O1<br />
fractures was 22%, for O2 38%, for O3A<br />
25% <strong>and</strong> for O3B 77%. 46% <strong>of</strong> O3B<br />
patients developed osteomyelitis <strong>and</strong><br />
required amputation.<br />
In marked contrast to these reports<br />
is our experience with complications<br />
after calcaneal reconstruction at<br />
Harborview Medical Center: the<br />
wound healing complication rate for all<br />
displaced calcaneal fractures is 2.4%<br />
<strong>and</strong> that for open fractures is 5.1%. No<br />
patients required calcanectomy or<br />
amputation as a result <strong>of</strong> their calcaneal<br />
fracture or subsequent care.<br />
Table 1: Fracture classification <strong>and</strong> s<strong>of</strong>t tissue status.<br />
METHODS AND MATERIALS<br />
Two groups were retrospectively<br />
reviewed: all displaced calcaneal<br />
fracture patients treated by the senior<br />
author from June 1994 to December<br />
1998 <strong>and</strong> those with open fractures<br />
from 1989 to 1998. The first group,<br />
which includes 252 fractures in 218<br />
patients, was established to investigate<br />
fracture repair <strong>and</strong> outcome. The<br />
sample size <strong>of</strong> the open group, which<br />
includes 37 patients with 39 open<br />
fractures, was increased by broadening<br />
the time frame. The radiographs <strong>and</strong><br />
wound <strong>of</strong> a representative patient with<br />
an O3A fracture are shown in Figure 1.<br />
Fracture classification <strong>and</strong> s<strong>of</strong>t tissue<br />
status for both groups are given in Table<br />
1. A lateral approach was used for all<br />
ORIF procedures; all incisions were<br />
closed with a two layer approach, using<br />
inverted mattress sutures in the deep<br />
layer <strong>and</strong> a horizontal modification <strong>of</strong><br />
the Allgöwer-Donati suture in the<br />
superficial layer. Cefazolin was<br />
administered perioperatively.<br />
Wound healing complications were<br />
established by review <strong>of</strong> patient records<br />
<strong>and</strong> follow-up contact. Patients<br />
requiring treatment beyond oral<br />
antibiotics were classified as having<br />
wound healing complications. The<br />
radiographs <strong>and</strong> wound from a<br />
representative patient with a wound<br />
healing problem is shown in Figure 2.<br />
Symptoms included persistent serous<br />
All 94-98 Open 89-98<br />
OTA fracture classification 73A1 4 1<br />
73B2 20 2<br />
73B3 3 2<br />
73C1 71 7<br />
73C2 64 13<br />
73C3 90 14<br />
S<strong>of</strong>t tissue status Closed 227 0<br />
01 3 4<br />
02 9 14<br />
03A 8 17<br />
03B 5 4<br />
discharge, erythema, diffuse cellulitis,<br />
<strong>and</strong> other evidence <strong>of</strong> infection.<br />
Treatments for patients with wound<br />
healing problems included course(s) <strong>of</strong><br />
intravenous antibiotics, irrigation <strong>and</strong><br />
debridement (I&D), <strong>and</strong> hardware<br />
removal. No methacillin resistant<br />
Staphylococcus were encountered. All<br />
patients with wound healing<br />
complications went on to heal their<br />
incisions <strong>and</strong> their calcaneal fractures.<br />
RESULTS<br />
Six feet (<strong>of</strong> 252, 2.4%) with closed<br />
fractures <strong>and</strong> two feet (<strong>of</strong> 39, 5.1%)<br />
with open fractures experienced wound<br />
healing problems that required<br />
intervention beyond oral antibiotics<br />
<strong>and</strong> that were directly associated with<br />
their open calcaneal fracture. The<br />
wound healing complication rate for<br />
O1 fractures was 0%, for O2 7%, for<br />
O3A 6% <strong>and</strong> for O3B O%. All feet that<br />
became infected eventually healed their<br />
wounds <strong>and</strong> fractures. Seven total<br />
infections were found: 6 (5 closed <strong>and</strong><br />
1 open) in the all fractures 1994-98<br />
group <strong>and</strong> an additional one in the<br />
open fractures 1989-98 group. The<br />
details are presented below.<br />
The first patient required I&D <strong>of</strong> a<br />
hematoma 14 days after the initial<br />
surgery. This relatively aggressive<br />
treatment was indicated because the<br />
patient had concurrent bilateral tibial<br />
fractures, was positive for hepatitis B<br />
<strong>and</strong> C, <strong>and</strong> had a recent history <strong>of</strong><br />
intravenous drug abuse <strong>and</strong> needle<br />
sharing. After I&D, he exhibited a<br />
typical progression <strong>of</strong> healing. Another<br />
non-diabetic, non-smoking <strong>and</strong><br />
compliant patient experienced<br />
persistent drainage from the apex <strong>of</strong> his<br />
lateral incision, developed erythema at<br />
four months, <strong>and</strong> required<br />
hospitalization to administer IV<br />
antibiotics. Cultures showed<br />
polymicrobial growth. The drainage<br />
resolved after the IV antibiotic course<br />
<strong>and</strong> the incision was healed by 7<br />
months post surgery.<br />
The next patient, a diabetic with<br />
bilateral fractures, was referred from<br />
out <strong>of</strong> town <strong>and</strong>, consequently, received<br />
most <strong>of</strong> his care in an outside facility.<br />
At the time <strong>of</strong> discharge from the initial<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 19
(A)<br />
(B)<br />
(C)<br />
(D)<br />
Figure 1: Patient with an O3A fracture. A) Lateral radiograph <strong>of</strong> injury; B) Open wound; C) Lateral radiograph <strong>of</strong> initial reduction; D) Lateral radiograph<br />
<strong>of</strong> reduction at 5 years.<br />
ORIF, his incisions appeared to be in<br />
excellent condition. On follow up here<br />
at six weeks <strong>and</strong> four months after<br />
surgery, his right foot was, however, not<br />
completely healed in the apex <strong>of</strong> the<br />
surgical incision. He was treated with<br />
antibiotics for Staphylococcus sp. <strong>and</strong><br />
experienced drainage <strong>and</strong> intermittent<br />
cellulitic symptoms until his hardware<br />
was removed nine months after surgery.<br />
This incision healed uneventfully.<br />
The next patient experienced<br />
persistent drainage from his incision<br />
that required IV antibiotics on two<br />
occasions; wound cultures grew<br />
Staphylococcus epidermidis. This<br />
patient had significant compliance<br />
problems <strong>and</strong> refused to consistently<br />
take his oral antibiotics or to quit<br />
smoking <strong>and</strong> was lost to follow up for<br />
several months. He also had hepatitis<br />
C for which he refused treatment. He<br />
reappeared at one year after his initial<br />
surgery <strong>and</strong> was noted to be cellulitic<br />
over the lateral aspect <strong>of</strong> the incision<br />
with a draining wound. His hardware<br />
was removed <strong>and</strong> he healed without<br />
further intervention.<br />
Another patient presented for initial<br />
treatment with a full thickness eschar<br />
on his heel <strong>of</strong> uncertain etiology <strong>and</strong><br />
required ORIF for a second metatarsal<br />
fracture in addition to the calcaneal<br />
fracture. His surgical incisions initially<br />
appeared to heal well, but ultimately<br />
became infected with Staphylococcus<br />
aureus. He developed a deep infection<br />
<strong>and</strong> required two episodes <strong>of</strong> I&D with<br />
IV antibiotics. His hardware was<br />
removed at ten months from the initial<br />
surgery <strong>and</strong> his foot healed without<br />
further complications. He eventually<br />
required a subtalar fusion to resolve<br />
chronic pain from subtalar arthritis,<br />
which developed due to the devastating<br />
nature <strong>of</strong> the initial injury, <strong>and</strong> healed<br />
uneventfully from this surgery.<br />
In an interesting case, a nonsmoking,<br />
compliant patient with<br />
bilateral, medially open fractures (O2,<br />
O3A) healed by primary intention, but<br />
began to spontaneously drain 10<br />
months after surgery from the lateral<br />
aspect <strong>of</strong> his left heel (O2), ultimately<br />
developing a deep infection. The<br />
hardware in his left foot was removed<br />
one year post surgery; cultures showed<br />
coagulase negative Staphylococcus<br />
epidermidis <strong>and</strong> Enterobacter cloacae.<br />
This incision healed uneventfully. The<br />
right foot (O3A) never developed<br />
wound healing problems.<br />
The final patient, a compliant nondiabetic<br />
smoker, had a medially open<br />
right calcaneus fracture (O3A) as well<br />
as closed left tibia-fibula <strong>and</strong> pelvic<br />
fractures. He never healed his calcaneal<br />
incision, developing a deep infection<br />
(Staphylococcus aureus) <strong>and</strong> requiring<br />
several courses <strong>of</strong> IV antibiotics.<br />
Hardware removal at one year after<br />
reconstruction did not stop the<br />
drainage. Finally, I&D, curettage <strong>and</strong><br />
placement <strong>of</strong> antibiotic beads (12<br />
methylene blue beads impregnated<br />
with tobramycin) at 2 years 3 months<br />
after initial surgery resolved the<br />
20 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
(A)<br />
(B)<br />
(C)<br />
(D)<br />
Figure 2: Patient with a wound healing complication (infection). A) Lateral radiograph <strong>of</strong> injury; B) Lateral radiograph <strong>of</strong> initial reduction; C) Infection<br />
at 1 year; D) Lateral radiograph <strong>of</strong> reduction at 1 year.<br />
infection <strong>and</strong> he went on complete<br />
healing.<br />
DISCUSSION<br />
Open wounds concurrent with<br />
calcaneal fractures are much more<br />
problematic than closed injuries<br />
because <strong>of</strong> the increased risk <strong>of</strong><br />
infection. Nonetheless, meticulous <strong>and</strong><br />
diligent care <strong>of</strong> the s<strong>of</strong>t tissue can<br />
remove much <strong>of</strong> the risk <strong>of</strong> infection<br />
in these patients, as it does in patients<br />
with closed injuries. Although the data<br />
presented here indicate that open<br />
calcaneal fractures are associated with<br />
higher rates <strong>of</strong> complication than<br />
closed fractures (2.4%), the overall rate<br />
<strong>of</strong> 5.1% should not be taken as a<br />
contraindication to open reduction <strong>and</strong><br />
internal fixation as the preferred<br />
method <strong>of</strong> treatment for this type <strong>of</strong><br />
injury. In all feet that experienced<br />
difficulties, the infections were treatable<br />
with I&D, antibiotics, <strong>and</strong> hardware<br />
removal. All patients healed their<br />
wounds. In no case was calcanectomy<br />
or amputation required.<br />
Although calcaneal fractures<br />
associated with open foot wounds<br />
present a substantial challenge,<br />
meticulous s<strong>of</strong>t tissue management<br />
allows these cases to be treated with the<br />
same techniques as closed fractures.<br />
Open reduction <strong>and</strong> internal fixation<br />
via the extensile lateral approach is the<br />
appropriate surgical technique because<br />
it can restore calcaneal anatomy after<br />
substantial disruption <strong>and</strong> s<strong>of</strong>t tissue<br />
trauma without exposing the patient to<br />
undue risk <strong>of</strong> complications. Surgical<br />
skill <strong>and</strong> patient compliance remain<br />
critical to success. As with closed<br />
calcaneal factures <strong>and</strong> other fractures<br />
<strong>of</strong> the weight-bearing system, anatomic<br />
reduction, stable internal fixation,<br />
atraumatic surgical technique, <strong>and</strong><br />
early mobilization is the treatment<br />
regime <strong>of</strong> choice.<br />
RECOMMENDED READING<br />
Barei DP, Bellabarba C, Sangeorzan BJ<br />
<strong>and</strong> Benirschke SK (<strong>2002</strong>) Fractures <strong>of</strong><br />
the Calcaneus. Orthopaedic Clinics <strong>of</strong><br />
North America, 33:263-285.<br />
Harvey EJ, Grujic L, Early JS,<br />
Benirschke SK, Sangeorzan BJ (2001)<br />
Morbidity associated with ORIF <strong>of</strong><br />
intra-articular calcaneus fractures using<br />
a lateral approach. Foot Ankle Int,<br />
22:868-73.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 21
Underst<strong>and</strong>ing <strong>and</strong> Preventing Cervical Spine Whiplash Injuries<br />
from Rear-end Motor Vehicle Collisions<br />
ALLAN F. TENCER, PH.D., SOHAIL K. MIRZA, M.D., KEVIN BENSEL, AND PHILIPPE HUBER<br />
Cervical spine whiplash injuries<br />
remain a common, expensive,<br />
<strong>and</strong> poorly understood health<br />
problem. The National Highway Traffic<br />
Safety Administration (NHTSA)<br />
reports that an average <strong>of</strong> 805,581<br />
whiplash injuries occurred annually in<br />
the United States between 1988 <strong>and</strong><br />
1996, with an annual estimated cost for<br />
treatment <strong>of</strong> $5.2 billion dollars.<br />
According to the Insurance Institute for<br />
Highway Safety (IIHS), only 5% <strong>of</strong> 1995<br />
model vehicles had a head restraint<br />
which allowed positioning above the<br />
top <strong>of</strong> the occupant’s head <strong>and</strong> closer<br />
than about 3 inches from the back <strong>of</strong><br />
the head. We have developed a research<br />
program to help prevent whiplash<br />
injuries by studying the mechanical<br />
deformations <strong>of</strong> the head <strong>and</strong> neck<br />
during a whiplash injury event <strong>and</strong><br />
finding ways to diminish these forces.<br />
Our research has included studying<br />
cases <strong>of</strong> whiplash injuries, conducting<br />
studies with human volunteers,<br />
developing computer models to<br />
simulate the impact, <strong>and</strong> studying<br />
tissue level changes in experiments<br />
using human cadaveric spine<br />
specimens. One goal <strong>of</strong> this research is<br />
to develop a head restraint with<br />
improved geometry <strong>and</strong> the ability to<br />
absorb energy from contact with the<br />
head during impact. This approach<br />
could reduce spinal forces <strong>and</strong> the<br />
potential for whiplash injury.<br />
METHODS<br />
Development <strong>of</strong> a modified head<br />
restraint<br />
A total <strong>of</strong> 432 actual low speed<br />
(under 7 mph) rear impacts were<br />
studied. Victims were primarily female,<br />
(70%), with an average age <strong>of</strong> 37 years,<br />
a height <strong>of</strong> 64 inches, <strong>and</strong> weight <strong>of</strong> 145<br />
lbs. Separate observations <strong>of</strong> 719 drivers<br />
showed that 26% had the head restraint<br />
set below ear level, <strong>and</strong> 42% had a gap<br />
<strong>of</strong> greater than about 3 inches between<br />
the back <strong>of</strong> the head <strong>and</strong> the restraint,<br />
Figure 1: Prototype retr<strong>of</strong>it head restraint mounts on posts <strong>of</strong> st<strong>and</strong>ard head restraint, couples to a<br />
front plate on the seat back to stiffen the head restraint to seat back connection, has an inflated air<br />
cushion (A) to contour to the occupant’s head neck <strong>and</strong> torso, with a discharge valve (B) to reduce<br />
rebound from the seat, <strong>and</strong> is higher <strong>and</strong> allows forward adjustment (C).<br />
either resulting from a kyphotic<br />
posture, or because the seat was<br />
inclined backwards. Impact testing <strong>of</strong><br />
seats demonstrated considerable<br />
variation in the stiffness <strong>of</strong> the head<br />
restraint <strong>and</strong> its ability to absorb the<br />
energy <strong>of</strong> contact with the head. These<br />
observations prompted the<br />
development <strong>of</strong> a modified head<br />
restraint, shown in Figure 1, which was<br />
higher <strong>and</strong> stiffer than existing devices.<br />
A pneumatic cushion (not an airbag)<br />
could be inflated to accommodate the<br />
shape <strong>of</strong> the occupant’s torso, spine, <strong>and</strong><br />
head, <strong>and</strong> a discharge valve on the<br />
cushion allowed air to escape from the<br />
bag, absorbing impact with the head.<br />
The response <strong>of</strong> human volunteers<br />
A representative vehicle seat was<br />
mounted on a 6 wheeled frame, Figure<br />
2. With IRB approval, 28 subjects were<br />
tested. Each subject was seated in the<br />
sled <strong>and</strong> restrained with lap <strong>and</strong><br />
shoulder belts. A light plastic headb<strong>and</strong><br />
was secured on the subject’s head<br />
containing accelerometers measuring X<br />
(forward-backward) <strong>and</strong> Z (upwarddownward)<br />
accelerations at<br />
approximately the level <strong>of</strong> each ear. The<br />
subject first underwent a rear end<br />
impact sitting upright against the<br />
modified head restraint with the air<br />
cushion inflated to the subject’s<br />
comfort level. Then the modified head<br />
restraint was replaced with the st<strong>and</strong>ard<br />
head restraint. The impact was<br />
equivalent to about a 4-5 mph rear-end<br />
collision.<br />
All subjects underwent the two<br />
sequential impacts without incident.<br />
Subsequent symptoms consisting <strong>of</strong><br />
some minor neck stiffness later that day<br />
or the next were reported by three<br />
subjects. All symptoms resolved rapidly.<br />
With the st<strong>and</strong>ard head restraint, Figure<br />
2, the subject’s chest was initially thrust<br />
forward while her head was falling<br />
backward toward the head restraint.<br />
Then her head was thrust forward as<br />
the chest motion stopped. With the<br />
modified head restraint, the subject’s<br />
head <strong>and</strong> torso were in nearly<br />
simultaneous contact with the seat <strong>and</strong><br />
head restraint <strong>and</strong> the maximum<br />
difference in horizontal position<br />
22 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Figure 2: Test subject on sled with headb<strong>and</strong> <strong>and</strong> chest plate containing accelerometers. Upper, modified head restraint, lower, the same subject with the<br />
st<strong>and</strong>ard head restraint. Note gap between head <strong>and</strong> head restraint in lower sequence (Time <strong>of</strong> images, from left to right, impact, 0 msec, 33 msec, 66 msec,<br />
132 msec).<br />
Figure 3: Computer model animation showing responses similar to volunteers <strong>and</strong>, in third frame forward thrust <strong>of</strong> torso with the head level causing anterior<br />
shearing <strong>of</strong> the cervical spine.<br />
Figure 4: Cadaveric cervical spine responses from left, at 1, 88, 144, <strong>and</strong> 228 msec. Note lower to middle cervical spine extension at 144 msec <strong>and</strong> flexion<br />
at 228 msec.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 23
etween the head (at the center <strong>of</strong><br />
gravity) <strong>and</strong> the sternum was reduced<br />
from about 48 mm to 20 mm.<br />
Measurements indicated lower peak<br />
accelerations <strong>and</strong> less variation in<br />
subject responses with the modified<br />
head restraint.<br />
Computer modeling<br />
MADYMO (Mathematical<br />
Dynamic Modeling, TNO Automotive,<br />
Delft Netherl<strong>and</strong>s) is used in the<br />
automotive industry for design <strong>of</strong> safety<br />
devices. It simulated the motion <strong>of</strong> the<br />
occupant modeled as rigid bodies (the<br />
bones) connected by joints, with<br />
properties well defined by cadaveric<br />
testing. The seat was modeled as a finite<br />
element object based on mechanical<br />
testing <strong>of</strong> the seat frame <strong>and</strong> cushion.<br />
Using this approach allowed the<br />
internal forces in the cervical spine to<br />
be defined since the model includes<br />
individual vertebrae <strong>and</strong> their<br />
connecting s<strong>of</strong>t tissues. Responses at<br />
impact speeds much higher than<br />
tolerable by volunteers were studied.<br />
Also, various properties <strong>of</strong> the seat were<br />
altered <strong>and</strong> the response <strong>of</strong> the<br />
occupant determined.<br />
The response <strong>of</strong> the model in terms<br />
<strong>of</strong> acceleration <strong>of</strong> the head <strong>and</strong> chest<br />
fell well within the responses measured<br />
in the volunteer studies described<br />
above. As shown in Figure 3, with a<br />
head restraint that reaches the top <strong>of</strong><br />
the occupant’s head <strong>and</strong> an initial gap<br />
<strong>of</strong> about 4 inches, the major force acting<br />
is shear, that is a horizontal force across<br />
the spinal vertebrae. With the head<br />
initially upright <strong>and</strong> momentarily<br />
stationary, while the torso is thrust<br />
forward by its contact with the seatback,<br />
an anterior shear or horizontal force<br />
acts on the cervical spine. Later, as the<br />
torso is stopped by the shoulder strap<br />
<strong>and</strong> the head is thrust forward by its<br />
contact with the head restraint, a<br />
secondary shear force develops.<br />
Reducing the head to restraint distance<br />
did not significantly alter these forces.<br />
It did prevent extension <strong>of</strong> the cervical<br />
spine <strong>and</strong> head but instead created<br />
greater flexion during the forward<br />
rebound <strong>of</strong> the head. Making the seat<br />
<strong>and</strong> head restraint s<strong>of</strong>ter decreased the<br />
magnitude <strong>of</strong> the primary shear force<br />
<strong>and</strong> reduced the head rebound from the<br />
restraint by absorbing energy, therefore<br />
decreasing the secondary shear force.<br />
Cadaveric Studies<br />
In order to gain insight into the<br />
detailed deformations <strong>of</strong> cervical spine<br />
tissues, a series <strong>of</strong> 11 cadaveric cervicothoracic<br />
specimens with an<br />
instrumented artificial skull was tested.<br />
Each specimen was mounted onto a<br />
platform, replacing the seat, on the<br />
same cart used for human volunteer<br />
testing. The same head restraint was<br />
used <strong>and</strong> the impactor was adjusted so<br />
that the acceleration at vertebra T1<br />
(about top <strong>of</strong> sternum level) was similar<br />
to that recorded by volunteers. High<br />
speed video was used to film the<br />
positions <strong>of</strong> markers on the lateral<br />
masses <strong>and</strong> the vertebral bodies <strong>and</strong><br />
measurements were made <strong>of</strong> the<br />
contact pressures in the facet joints, <strong>and</strong><br />
around the nerve roots. The effect <strong>of</strong><br />
the modified head restraint was<br />
studied.<br />
Figure 4 showed formation <strong>of</strong> a<br />
partial “S” curvature, specifically<br />
extension <strong>of</strong> the lower cervical spine<br />
which seemed to be most prominent<br />
when the head motion was stopped by<br />
the head restraint. Following rebound<br />
from the head restraint the spine was<br />
subjected to both anterior shear <strong>and</strong><br />
tensile forces as the head moved<br />
forward <strong>of</strong> the lower spine.<br />
Reproducible pressure pulses occurred<br />
around the nerve roots, highest at levels<br />
C7-T1, <strong>and</strong> were maximum after peak<br />
acceleration <strong>of</strong> the chest but before peak<br />
acceleration <strong>of</strong> the head occurred.<br />
Pressure measurements in the facets<br />
showed pinching (a high pressure point<br />
in the joint instead <strong>of</strong> a uniform<br />
contact), in about 70% <strong>of</strong> tests, with<br />
C4-5 <strong>and</strong> C5-6 having the greatest<br />
likelihood <strong>of</strong> pinching. The modified<br />
head restraint reduced head<br />
acceleration <strong>and</strong> resulting spinal shear<br />
forces by about 30%.<br />
CONCLUSION<br />
In a rear-end vehicle impact, even<br />
when the occupant’s head is positioned<br />
close to the head restraint, significant<br />
forces can be developed in the cervical<br />
spine with resulting intervertebral<br />
displacements <strong>and</strong> tissue pressures <strong>and</strong><br />
deformations. These forces are a<br />
primary anterior shear, due to the torso<br />
being thrust under the stationary head<br />
by its contact with the seat, <strong>and</strong> a<br />
secondary force from the head being<br />
thrust forward by its contact with the<br />
head restraint as the torso motion stops.<br />
The basic method for reducing spinal<br />
forces <strong>and</strong> intersegmental<br />
displacements is to s<strong>of</strong>ten the torso-toseat<br />
<strong>and</strong> head-to-restraint contact, <strong>and</strong><br />
importantly, use the head restraint to<br />
absorb the energy <strong>of</strong> these impacts.<br />
RECOMMENDED READING<br />
Insurance Institute for Highway Safety<br />
“Whiplash Injuries”, Status Report,<br />
30:no 8, pp1-12, Sept 16, 1995.<br />
Tencer AF, Mirza SK, Bensel K, The<br />
response <strong>of</strong> human volunteers to rearend<br />
impacts, The effect <strong>of</strong> head<br />
restraint properties, Spine, 26: Nov,<br />
2001.<br />
Tencer AF, Mirza SK, Bensel KD,<br />
Internal loads in the cervical spine<br />
during motor vehicle rear-end impacts:<br />
The effect <strong>of</strong> acceleration <strong>and</strong> head-tohead<br />
restraint proximity, Spine, 27: Jan,<br />
2001.<br />
Tencer AF, Mirza SK, Cummings, P, Do<br />
whiplash victims with neck pain differ<br />
from those with neck pain <strong>and</strong> other<br />
symptoms Proceedings <strong>of</strong> the<br />
Association for the Advancement <strong>of</strong><br />
Automotive Medicine, Sept, 2001.<br />
Ono, K, Kaneoka K, Wittek, A, Kajzer J,<br />
Cervical injury mechanism based on<br />
the analysis <strong>of</strong> human cervical vertebral<br />
motion <strong>and</strong> head-neck-torso<br />
kinematics during low speed rear<br />
impacts, Transactions <strong>of</strong> the Society <strong>of</strong><br />
Automotive Engineers, 973340, 1997.<br />
Yogan<strong>and</strong>an, N, Pintar FA, Cusick, J,<br />
Biomechanical analyses <strong>of</strong> whiplash<br />
injuries using experimental models,<br />
Proceedings <strong>of</strong> the World Congress on<br />
Whiplash <strong>and</strong> Associated Disorders,<br />
Vancouver, BC, Feb, 1999, pp 325-344,<br />
1999.<br />
Deng B, Begeman PC, Yang KH,<br />
Tashman S, King AI, Kinematics <strong>of</strong><br />
human cadaver cervical spine during<br />
low speed rear-end impacts, STAPP Car<br />
Crash Journal, 44:171-188, 2000.<br />
24 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Accuracy <strong>and</strong> Reproducibility <strong>of</strong> Step <strong>and</strong> Gap Measurements<br />
from Plain Radiographs After Intra-Articular Fracture <strong>of</strong> the<br />
Distal Radius<br />
WREN V. MCCALLISTER, M.D., JEFFREY M. SMITH, M.D., JEFF KNIGHT, B.S.,<br />
AND THOMAS E. TRUMBLE, M.D.<br />
Recent reports have highlighted<br />
the important relationship<br />
between residual intra-articular<br />
displacement <strong>and</strong> the long-term<br />
outcome <strong>of</strong> distal radius fractures.<br />
There appears to be a general consensus<br />
that accelerated development <strong>of</strong><br />
arthritis <strong>and</strong> worsened severity <strong>of</strong><br />
degenerative changes is associated with<br />
residual step-<strong>of</strong>f displacements greater<br />
than 1 to 2 millimeters. Therefore, to<br />
improve clinical outcome after intraarticular<br />
fracture <strong>of</strong> the distal radius,<br />
many reports in the literature strongly<br />
advocate surgical reduction <strong>of</strong><br />
fragments with articular incongruities<br />
greater than 1 to 2 millimeters. In each<br />
<strong>of</strong> these studies, the intra-articular step<strong>of</strong>f<br />
<strong>and</strong> gap displacements were<br />
measured in millimeters using plain<br />
radiographs.<br />
Definitive st<strong>and</strong>ards for describing<br />
<strong>and</strong> quantifying articular surface<br />
incongruity do not exist. Kreder et al.<br />
in 1996 attempted to st<strong>and</strong>ardize the<br />
technique for measuring intra-articular<br />
displacement <strong>of</strong> distal radius fractures.<br />
Sixteen observers examined six<br />
radiographs <strong>of</strong> healed intra-articular<br />
distal radius fractures <strong>and</strong> found that,<br />
“…even experienced clinicians did not<br />
readily agree on the size <strong>of</strong> step <strong>and</strong> gap<br />
deformity.” Specifically, they found that<br />
two experienced observers chosen at<br />
r<strong>and</strong>om to measure step-<strong>of</strong>f <strong>and</strong> gap<br />
displacement would differ by 3<br />
millimeters or more at least 10% <strong>of</strong> the<br />
time, while the same observer making<br />
repeat measurements would be<br />
expected to differ by 2 millimeters at<br />
least 10% <strong>of</strong> the time. Singer also<br />
demonstrated significant interobserver<br />
variability in the measurement <strong>of</strong> intraarticular<br />
distal radius fracture fragment<br />
displacement using plain radiographs.<br />
To date, the accurate <strong>and</strong> reliable<br />
measurement <strong>of</strong> intra-articular fracture<br />
displacements <strong>of</strong> less than 2 millimeters<br />
from plain radiographs has not been<br />
established.<br />
The purpose <strong>of</strong> this study was to<br />
determine the accuracy <strong>and</strong><br />
reproducibility <strong>of</strong> measured step-<strong>of</strong>f<br />
<strong>and</strong> gap displacements involving the<br />
articular surface <strong>of</strong> the distal radius.<br />
Our hypothesis was that step-<strong>of</strong>f <strong>and</strong><br />
gap displacements <strong>of</strong> 2 millimeters or<br />
less would show poor accuracy <strong>and</strong><br />
reproducibility for both intra- <strong>and</strong><br />
inter-observer measurements. This<br />
study differs from others in that by<br />
using cadaver specimens, we have<br />
created a gold st<strong>and</strong>ard for the fracture<br />
displacements. Earlier studies, lacking<br />
such a gold st<strong>and</strong>ard, were limited to<br />
comparisons among observers <strong>and</strong><br />
could not comment on the accuracy <strong>of</strong><br />
measurement. Further, our cadaver<br />
model mimics intra-articular fracture<br />
in the acute setting. As Kreder et al.<br />
acknowledge, “It may well be that some<br />
parameters (such as step <strong>and</strong> gap<br />
deformity) are more readily quantified<br />
in the acute setting, since fracture lines<br />
have not been obscured by the healing<br />
process.” Finally, by computing<br />
tolerance limits, we attempt to define a<br />
reliable threshold for the accuracy <strong>and</strong><br />
reliability <strong>of</strong> plain film radiography in<br />
the setting <strong>of</strong> intra-articular distal<br />
radius fractures. Such information has<br />
value to the clinician in the decisionmaking<br />
process regarding the use <strong>of</strong> CT<br />
imaging.<br />
METHODS<br />
A Melone three-part fracture was<br />
created in cadaver forearms to generate<br />
a total <strong>of</strong> 12 combinations <strong>of</strong> step <strong>and</strong><br />
gap displacement (Figure 1). The range<br />
<strong>of</strong> step deformity was 3.5mm (0.5 min,<br />
4.0 max) <strong>and</strong> the range <strong>of</strong> gap<br />
deformity was 3.9mm (0.1 min, 4.0<br />
max). The radiographs were examined<br />
by 22 physicians (divided into three<br />
groups based on skill level: Group 1: six<br />
R1 <strong>and</strong> R2 level orthopaedic surgery<br />
residents; Group 2: four R4 senior<br />
orthopaedic surgery residents on the<br />
H<strong>and</strong> service, five H<strong>and</strong> Fellows; Group<br />
3: six experienced Attending h<strong>and</strong><br />
surgeons <strong>and</strong> one musculoskeletal<br />
radiologist) in a blinded, r<strong>and</strong>omized<br />
fashion using a st<strong>and</strong>ardized technique.<br />
Twice each physician (range 3 weeks to<br />
Step-<strong>of</strong>f<br />
Gap<br />
Inter Intra Inter Intra<br />
ICC * 0.78 0.81 0.85 0.89<br />
κκ ** 0.64 0.65 0.65 0.76<br />
Tolerance (mm) 2.58 1.76 2.51 1.61<br />
Table 1: Results for inter- <strong>and</strong> intra-observer measurements (see Methods for explanation). * L<strong>and</strong>is & Koch agreement criteria: 0.80 almost perfect.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 25
RESULTS<br />
Table 1 shows the overall results for<br />
this study. For all data in this study,<br />
there were no statistically significant<br />
differences based upon skill level. The<br />
overall average observation was<br />
accurate to within .62 ± .53 millimeters<br />
(95% C.I. .59 to .65). Radiographs in<br />
which the beam was parallel to the<br />
plane <strong>of</strong> fracture had an observer<br />
accuracy <strong>of</strong> .58 ± .47 millimeters. For<br />
radiographs <strong>of</strong> specimens number two,<br />
four <strong>and</strong> six, which did not have the x-<br />
ray beam parallel to the plane <strong>of</strong><br />
fracture, observer accuracy decreased to<br />
.72 ± .70 millimeters (p 2mm).<br />
Tolerance limits were calculated to<br />
describe the value x for which 95% <strong>of</strong><br />
all measurements will be within ± x<br />
90% <strong>of</strong> the time. The accuracy <strong>of</strong> raters<br />
was determined by calculating the<br />
accuracy <strong>of</strong> measurement, mean <strong>and</strong><br />
st<strong>and</strong>ard deviation for each observer.<br />
Fern<strong>and</strong>ez DL, Geissler WB. Treatment<br />
<strong>of</strong> displaced articular fractures <strong>of</strong> the<br />
radius. J H<strong>and</strong> Surg [Am]. 1991<br />
May;16(3):375-84.<br />
Knirk JL, Jupiter JB. Intra-articular<br />
fractures <strong>of</strong> the distal end <strong>of</strong> the radius<br />
in young adults. J <strong>Bone</strong> <strong>Joint</strong> Surg Am.<br />
1986 Jun;68(5):647-59.<br />
Kreder HJ, Hanel DP, McKee M, Jupiter<br />
J, McGillivary G, Swiontkowski MF. X-<br />
ray film measurements for healed distal<br />
radius fractures. J H<strong>and</strong> Surg [Am].<br />
1996 Jan;21(1):31-9.<br />
Trumble TE, Schmitt SR, Vedder NB.<br />
Factors affecting functional outcome <strong>of</strong><br />
displaced intra-articular distal radius<br />
fractures. J H<strong>and</strong> Surg [Am]. 1994<br />
Mar;19(2):325-40.<br />
26 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Genomic Sequences <strong>and</strong> Expression <strong>of</strong> the RNA Splicing Factors<br />
TASR-1 <strong>and</strong> TASR-2<br />
JEREMIAH M. CLINTON, B.S., HOWARD A. CHANSKY, M.D., A. ZIELINSKA-KWIATKOWSKA, M.D.,<br />
ERNEST U. CONRAD, M.D., AND LIU YANG, PH.D.<br />
Genes are transcribed into<br />
protein by a complex <strong>of</strong><br />
enzymes named RNA<br />
polymerase II (Pol II). Before being<br />
exported from the nucleus to the<br />
cytoplasm as mature messenger RNAs<br />
(mRNA), pre-messenger RNA<br />
transcripts undergo extensive<br />
modification including splicing.<br />
Splicing, simply put, allows different<br />
portions <strong>of</strong> a gene to be assembled in<br />
several different ways, thus increasing<br />
the complexity <strong>of</strong> proteins without<br />
increasing the number <strong>of</strong> genes. The<br />
selection <strong>of</strong> alternative splicing<br />
pathways represents an important step<br />
in eukaryotic gene expression. For<br />
example, alternative splicing controls<br />
sex determination in fruit flies <strong>and</strong><br />
alternative splicing <strong>of</strong> type II collagen<br />
appears to play important roles in both<br />
development <strong>of</strong> the skeleton <strong>and</strong><br />
osteoarthritis. Aberrant RNA splicing<br />
is also commonly observed in leukemia<br />
<strong>and</strong> solid tumors <strong>and</strong> probably exerts<br />
its effects by altering the expression <strong>of</strong><br />
cell-cycle proteins.<br />
The so-called ‘SR’ splicing factors<br />
contain multiple serine (S) <strong>and</strong><br />
arginine (R) amino acids <strong>and</strong> play a<br />
critical role in RNA splicing. Individual<br />
SR proteins show specificity toward<br />
different pre-mRNAs <strong>and</strong> may display<br />
unique roles in cell growth <strong>and</strong><br />
development. Our studies suggest that<br />
TLS <strong>and</strong> EWS, proteins implicated in<br />
the genesis <strong>of</strong> leukemia <strong>and</strong> sarcomas,<br />
may function as adapter molecules that<br />
recruit specific SR proteins to RNA Pol<br />
II, thus coupling gene transcription to<br />
RNA splicing. We have identified <strong>and</strong><br />
studied two new SR proteins, TLSassociated<br />
SR protein-1 <strong>and</strong> TLSassociated<br />
protein–2 (TASR-1 <strong>and</strong><br />
TASR-2), that bind to normal Ewing’s<br />
sarcoma protein (EWS) <strong>and</strong> TLS<br />
(“translocated in liposarcoma”).<br />
EWS <strong>and</strong> TLS are involved in<br />
translocations that are very likely to be<br />
the critical steps in the development <strong>of</strong><br />
Ewing’s sarcoma, liposarcomas,<br />
chondrosarcomas, as well as other rarer<br />
sarcomas. A fusion protein resulting<br />
from a translocation may have different<br />
biochemical <strong>and</strong> functional properties<br />
than the two component proteins from<br />
which it is derived. For myxoid<br />
liposarcoma <strong>and</strong> Ewing’s sarcoma, the<br />
corresponding fusion proteins are TLS/<br />
CHOP <strong>and</strong> EWS/Fli-1, respectively.<br />
Unlike normal EWS <strong>and</strong> TLS, these<br />
fusion proteins are unable to bind to<br />
either TASR-1 or –2 <strong>and</strong> we have<br />
demonstrated that this results in<br />
dysregulation <strong>of</strong> RNA splicing.<br />
Disruption <strong>of</strong> EWS <strong>and</strong> TLS-mediated<br />
splicing pathways by fusion proteins<br />
may lead to degradation <strong>of</strong> unprocessed<br />
pre-mRNA or the generation <strong>of</strong><br />
alternatively spliced products, with<br />
potentially pr<strong>of</strong>ound affects on gene<br />
expression in Ewing’s <strong>and</strong> liposarcoma<br />
cells.<br />
Little is known about the structure<br />
<strong>and</strong> function <strong>of</strong> TASR proteins. TASR-<br />
1 <strong>and</strong> -2 share identical N-terminal<br />
domains <strong>and</strong> differ in their C-terminal<br />
regions; however it is not clear whether<br />
the two proteins are encoded by<br />
separate genes or are the products <strong>of</strong><br />
alternative splicing <strong>of</strong> the same primary<br />
transcript. The purpose <strong>of</strong> this study<br />
was to first determine whether TASR-1<br />
<strong>and</strong> –2 are encoded by two different<br />
genes. Depending upon this result, we<br />
wanted to obtain the DNA sequence for<br />
one or both genes. Finally, we studied<br />
expression patterns <strong>of</strong> these proteins to<br />
identify any tissue specificity.<br />
METHODS<br />
TASR proteins are evolutionally<br />
conserved, to the degree that mouse<br />
<strong>and</strong> human TASR have identical<br />
protein sequences. In an attempt to<br />
identify mouse <strong>and</strong> human genomic<br />
sequences for TASR-1 <strong>and</strong> TASR-2.<br />
Specific DNA primers were designed<br />
based upon their cDNA sequences <strong>and</strong><br />
polymerase chain reaction (PCR) was<br />
performed with these primers. The<br />
DNAs corresponding to human TASR-<br />
1 <strong>and</strong> TASR-2 genes were amplified<br />
using Hela cell genomic DNA as the<br />
template. The DNAs corresponding to<br />
mouse TASR-1 <strong>and</strong> TASR-2 genes were<br />
amplified using L-cell genomic DNA as<br />
the template. After separation on<br />
agarose gel, both mouse <strong>and</strong> human<br />
genomic DNAs were purified <strong>and</strong><br />
sequenced.<br />
To determine the level <strong>of</strong> expression<br />
<strong>of</strong> the TASR proteins in different cell<br />
lines, Western Blotting was performed<br />
using lysates from two Ewing’s cell lines<br />
(SK-N-MC & SK-ES) as well as HeLa<br />
cells. TASR-1 is highly expressed in<br />
Figure 1: Structure <strong>of</strong> theTASR gene, schematic <strong>of</strong> splicing <strong>and</strong> polyadenylation. (a), The approximate location <strong>of</strong> each exon within the TASR transcription unit<br />
is depicted as an open box <strong>and</strong> numbered below. While TASR-2 mRNA is generated by transcription from exon I through exon VI, TASR-1 mRNA does not<br />
retain any sequence from exon VI but instead contains sequence from exon VII. Bold line represents the promoter region <strong>and</strong> arrows indicate the approximate<br />
locations <strong>of</strong> polyadenylation signals.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 27
Ewing’s cell lines; SK-ES cells have<br />
higher expression than SK-N-MC <strong>and</strong><br />
both have higher levels <strong>of</strong> expression<br />
than HeLa cells. Northern blotting was<br />
performed to examine the expression<br />
<strong>of</strong> TASR proteins in different tissues.<br />
TASR mRNAs were found to be<br />
ubiquitously expressed <strong>and</strong> are most<br />
abundant in testis.<br />
Figure 2: TASR expression in mouse tissues. Poly (A) mRNA from mouse tissues blotted with a DNA<br />
probe specific for both TASR 1 <strong>and</strong> 2. Molecular Weight is indicated on the left. Tissue type is above<br />
the corresponding lane. Specific TASR expression is indicated by arrows with MW in parenthesies.<br />
Figure 3: This is an example <strong>of</strong> a peripheral neuroectodermal tumor, a variant <strong>of</strong> Ewing’s Sarcoma.<br />
These remain devastating diseases thus the need for continued basic research.<br />
RESULTS AND DISCUSSION<br />
Sequencing analysis <strong>of</strong> mouse <strong>and</strong><br />
human genomic DNAs revealed that<br />
TASR-1 <strong>and</strong> 2 are in fact encoded by a<br />
single gene in each species <strong>and</strong> are the<br />
result <strong>of</strong> alternative splicing. Even<br />
though TASR-1 <strong>and</strong> TASR-2 share the<br />
same sequence in the 5’ untranslated<br />
region <strong>and</strong> in the region encoding the<br />
N-terminal domain, these two genes<br />
diverge in regions encoding the C-<br />
terminal domain <strong>and</strong> the 3’<br />
untranslated region. Several<br />
polyadenylation sites are observed in<br />
both TASR-1 <strong>and</strong> 2 genomic sequences,<br />
resulting in the generation <strong>of</strong> multiple<br />
mRNA transcripts encoding each TASR<br />
protein. The range <strong>of</strong> expression <strong>of</strong> the<br />
splicing <strong>and</strong> polyadenylation variants<br />
<strong>of</strong> the TASR gene in human tissue may<br />
reflect their essential roles in the proper<br />
control <strong>of</strong> cell growth <strong>and</strong><br />
differentiation.<br />
It also appears that pseudogenes are<br />
present within the human <strong>and</strong> mouse<br />
genomic sequences for both TASR-1<br />
<strong>and</strong> 2. Pseudogenes in essence are<br />
nonfuntional stretches <strong>of</strong><br />
complementary DNA, or “retroposons”,<br />
that have been introduced into the<br />
genome by reverse transcriptions. This<br />
is significant because it demonstrates<br />
that the TASR proteins are<br />
evolutionarily ancient <strong>and</strong> that they are<br />
critical molecules in the normal<br />
physiology <strong>of</strong> mammalian cells. This is<br />
confirmed by the Northern blot results<br />
which showed that the TASR proteins<br />
are ubiquitously expressed.<br />
The expression <strong>of</strong> TASR 1 was<br />
found to be highly expressed in Ewing’s<br />
sarcoma cell lines versus Hela cells. This<br />
may represent a compensatory<br />
response by the Ewing’s cells to the<br />
EWS/Fli-1-mediated disruption <strong>of</strong> the<br />
normal interaction between TASR<br />
proteins <strong>and</strong> EWS. These splicing<br />
proteins appear to play an importaant<br />
role in the development <strong>of</strong> a variety <strong>of</strong><br />
sarcomas. Underst<strong>and</strong>ing the structure<br />
<strong>of</strong> TASR-1 <strong>and</strong> TASR-2 is an important<br />
step towards developing targeted<br />
28 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
molecular treatments for these<br />
devastating cancers.<br />
RECOMMENDED READING:<br />
Yang L, Chansky HA, Hickstein DD.:<br />
EWS/Fli-1 fusion protein interacts with<br />
hyperphosphorylated RNA polymerase<br />
II <strong>and</strong> interferes with serine-arginine<br />
protein-mediated RNA splicing. J Biol<br />
Chem. 2000 Dec 1;275(48):37612-8.<br />
Knoop LL, Baker SJ.: The splicing factor<br />
U1C represses EWS/FLI-mediated<br />
transactivation. J Biol Chem. 2000 Aug<br />
11;275(32):24865-71.<br />
Ohno T, Ouchida M, Lee L, Gatalica Z,<br />
Rao VN, Reddy ES.: The EWS gene,<br />
involved in Ewing family <strong>of</strong> tumors,<br />
malignant melanoma <strong>of</strong> s<strong>of</strong>t parts <strong>and</strong><br />
desmoplastic small round cell tumors,<br />
codes for an RNA binding protein with<br />
novel regulatory domains.<br />
Oncogene. 1994 Oct;9(10):3087-97.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 29
The Role <strong>of</strong> Fusion Protein-Induced Alternative Splicing in the<br />
Development <strong>of</strong> Ewing’s Sarcoma<br />
DAVID D. ODELL, B.S., HOWARD A. CHANSKY, M.D., A. ZIELINSKA-KWIATKOWSKA, M.D.,<br />
AND LIU YANG, PH.D.<br />
Cancers arise when genetic<br />
changes, such as chromosomal<br />
translocations <strong>and</strong> point<br />
mutations, enable cells to escape the<br />
control mechanisms that usually serve<br />
to limit cell division to periods <strong>of</strong><br />
growth or normal replenishment <strong>of</strong><br />
cells. A better underst<strong>and</strong>ing <strong>of</strong> the<br />
specific pathways that lead from a<br />
genetic change to a cancerous cell may<br />
yield targets for molecular treatments.<br />
Ewing’s sarcoma is a malignant<br />
neoplasm <strong>of</strong> bone <strong>and</strong> s<strong>of</strong>t tissue. A<br />
chromosomal translocation, t(11;22)<br />
that fuses two distinct genes is<br />
associated with a large percentage<br />
(85%) <strong>of</strong> Ewing’s tumors. The<br />
translocation results in the Ewing’s<br />
sarcoma protein (EWS) being fused to<br />
the DNA binding domain <strong>of</strong> the ETS<br />
transcription factor Fli-1 (Figure 1).<br />
These fusion proteins retain the N-<br />
terminal portion <strong>of</strong> normal EWS (WT-<br />
EWS) while the fusion partner Fli-1<br />
replaces the C-terminal portion <strong>of</strong> WT-<br />
EWS. The N-terminal portion <strong>of</strong><br />
normal EWS has been found to bind<br />
the largest subunit <strong>of</strong> the RNA<br />
polymerase II (Pol II) complex, an<br />
enzyme necessary for transcription <strong>of</strong><br />
genes from DNA to messenger RNA<br />
(mRNA). The C-terminal domain <strong>of</strong><br />
normal EWS recruits proteins referred<br />
to as serine-arginine (SR) splicing<br />
factors that function in splicing the <strong>of</strong><br />
pre-mRNA to mRNA. The EWS/Fli-1<br />
fusion protein retains the ability to bind<br />
RNA Pol II. However, EWS/Fli-1<br />
cannot recruit SR proteins due to the<br />
replacement <strong>of</strong> its C-terminal domain<br />
by the Fli-1fusion partner.<br />
The EWS/Fli-1 fusion protein was<br />
originally believed to induce cellular<br />
transformation through improper<br />
activation <strong>of</strong> Fli-1 target genes.<br />
However, new evidence indicates that<br />
the EWS/Fli-1 fusion protein may<br />
interfere with adapter functions <strong>of</strong><br />
normal-EWS. In an adenovirus E1A<br />
splicing model, EWS/Fli-1 has been<br />
shown to alter splicing <strong>of</strong> exogenous<br />
pre-mRNA when compared to ‘normal’<br />
splicing patterns mediated by WT-<br />
EWS. This study was designed to test<br />
the effects <strong>of</strong> inhibiting expression <strong>of</strong><br />
EWS/Fli-1 on patterns <strong>of</strong> splicing <strong>of</strong><br />
molecules implicated in the<br />
development <strong>of</strong> sarcomas.<br />
RESULTS<br />
Using the Ewing’s sarcoma cell line<br />
SK-N-MC as a model system, a series<br />
<strong>of</strong> transfections were performed to<br />
integrate a “doxycycline-<strong>of</strong>f” antisense<br />
EWS/Fli-1 construct into the genome<br />
<strong>of</strong> the Ewing’s cells. In this system, sense<br />
EWS/Fli-1 is expressed in the presence<br />
<strong>of</strong> doxycycline but upon withdrawal <strong>of</strong><br />
doxycycline the antisense EWS/Fli-1<br />
construct is expressed. Antisense EWS/<br />
FLI-1 then inhibits expression <strong>of</strong> the<br />
‘normal’ EWS/FLI-1 sarcoma protein.<br />
In our genetically engineered Ewing’s<br />
sarcoma cells, induction <strong>of</strong> antisense<br />
EWS/Fli-1 was monitored through the<br />
co-expression <strong>of</strong> green fluorescent<br />
protein (GFP) that could be visualized<br />
using laser light (Figure 2). RT-PCR<br />
analysis <strong>of</strong> EWS/FLI-1 mRNA <strong>and</strong><br />
Western blotting <strong>of</strong> the EWS/Fli-1<br />
fusion protein were used to monitor<br />
EWS/Fli-1 expression in induced <strong>and</strong><br />
non-induced Ewing’s sarcoma cells.<br />
The inducible expression <strong>of</strong> EWS/<br />
Fli-1 antisense RNA proved to be<br />
effective in reducing the quantity <strong>of</strong><br />
EWS/Fli-1 fusion protein to a negligible<br />
level after withdrawal <strong>of</strong> doxycycline<br />
from the culture medium. Comparison<br />
<strong>of</strong> cellular growth rates indicated that<br />
antisense expression correlated with a<br />
decrease in the proliferation <strong>of</strong> Ewing’s<br />
sarcoma cells (Figure 3). In addition,<br />
RT-PCR analysis showed that downregulation<br />
<strong>of</strong> EWS/Fli-1 leads to<br />
changes in mRNA splicing patterns for<br />
the cell surface marker CD44 <strong>and</strong> the<br />
tumor suppressor Bin-1.<br />
DISCUSSION<br />
The EWS/Fli-1 fusion protein is the<br />
hallmark <strong>of</strong> Ewing’s tumors, yet little is<br />
Figure 1: The normal structures <strong>of</strong> the EWS <strong>and</strong> Fli-1 genes are shown with the point <strong>of</strong> fusion indicated on the wild-type EWS gene. The N-terminal RNA Pol<br />
II binding domain remains in the fusion protein while the C-terminal splicing factor-recruiting domain is replaced by the Fli-1 DNA binding domain.<br />
30 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
(A)<br />
(B)<br />
Figure 2: GFP expression was monitored under laser light (488 nm) in induced cells (A) <strong>and</strong> uninduced<br />
cells (B). Only those cells that were induced show significant expression <strong>of</strong> GFP.<br />
implications as a general mechanism<br />
for the initiation <strong>of</strong> tumor<br />
development.<br />
Our results showed that the EWS/<br />
Fli-1 fusion protein was successfully<br />
down-regulated by the expression <strong>of</strong><br />
antisense EWS/Fli-1 RNA in Ewing’s<br />
cells. This inducible system permits us<br />
to study genetically identical cells that<br />
differ only in the presence or absence<br />
<strong>of</strong> the EWS/FLI-1 fusion protein. As<br />
appropriate control constructs are also<br />
used, any changes in splicing patterns<br />
in these cells should therefore be<br />
attributable to the effect <strong>of</strong> the fusion<br />
protein itself.<br />
Alternatively spliced forms <strong>of</strong><br />
CD44 <strong>and</strong> Bin-1, proteins important in<br />
cell growth <strong>and</strong> differentiation, were<br />
identified by comparison <strong>of</strong> splicing<br />
patterns before <strong>and</strong> after the EWS/Fli-<br />
1 fusion protein was down-regulated.<br />
CD44 splice variants have been<br />
associated with increased invasiveness<br />
<strong>and</strong> loss <strong>of</strong> contact inhibition in tumor<br />
cells. Alternatively spliced forms <strong>of</strong> Bin-<br />
1 no longer possess the ability to<br />
interact with the protein myc, resulting<br />
in the inability <strong>of</strong> myc to function as a<br />
tumor suppressor. Our findings<br />
indicate that aberrant splicing <strong>of</strong> premRNA,<br />
as mediated by the EWS/Fli-1<br />
fusion protein, may explain the myriad<br />
changes in gene expression that<br />
transform a benign mesenchymal cell<br />
into a malignant sarcoma.<br />
RECOMMENDED READING<br />
Figure 3: The proliferation rates <strong>of</strong> induced <strong>and</strong> uninduced cells were measured over 72 hours. Equal<br />
numbers <strong>of</strong> cells were initially seeded <strong>and</strong> counted at each time point using tryphan blue staining to<br />
identify viable cells. Uninduced cells exhibited a greater rate <strong>of</strong> proliferation than the induced cells<br />
since the fusion protein confers a growth advantage in Ewing’s cells.<br />
known about its functional effects on<br />
cells. This study explored the possibility<br />
that the fusion protein could promote<br />
tumorigenesis by interfering with<br />
mRNA splicing in Ewing’s cells.<br />
Aberrant splicing <strong>of</strong> pre-mRNA is a<br />
poorly understood but common<br />
feature <strong>of</strong> human tumors. Because<br />
alternative splicing can lead to the<br />
expression <strong>of</strong> nonfunctional proteins or<br />
proteins with altered activity, this<br />
process might have important<br />
Rapp, T.B., Yang, L., Conrad, E.U.,<br />
M<strong>and</strong>ahl, N., Chansky, H.A. J. Orthop.<br />
Res., Submitted November, 2001.<br />
Chansky, H.A., Hu, M., Hickstein, D.D.,<br />
Yang, L. (2001) Cancer Res. 61 3586-<br />
3590.<br />
Yang, L., Chansky, H.A., <strong>and</strong><br />
Hickstein,D.D. (2000) J. Biol. Chem.<br />
273, 37612-37618.<br />
Ge, K., DuHadaway, J., Du, W., et al.<br />
(1999) Proc. Natl. Acad. Sci.USA 96,<br />
9689-9694.<br />
Sneath, R.J.S., Manghan, D.C. (1998)<br />
J. Clin. Pathol.: Mol. Pathol. 51 191-200.<br />
Delattre, O., Zucman, J., Plougastel, B.<br />
et al. (1992) Nature 359, 162-165.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 31
Using a Freeze Fixation Technique <strong>and</strong> Histological Crimp<br />
Analysis for Mapping the Strain in Functionally Loaded<br />
Ligaments<br />
RICHARD BOORMAN, M.D., M.SC., TONY NORMAN, B.S.E., FREDERICK A. MATSEN III, M.D.,<br />
AND JOHN CLARK, M.D., PH.D.<br />
In a non-loaded state, type I collagen<br />
fibrils in tendons <strong>and</strong> ligaments<br />
assume a sinusoidal wave shape that<br />
disappears with modest tensile loads<br />
(Gathercole <strong>and</strong> Keller, 1991). This<br />
“crimp” is visible by polarized light<br />
microscopy because collagen fibrils are<br />
aligned in uniform register. A better<br />
underst<strong>and</strong>ing <strong>of</strong> how ligaments<br />
distribute load may yield critical<br />
information on how they fail with<br />
injury <strong>and</strong> disease. Yet the response <strong>of</strong><br />
crimp to load has, by necessity, been<br />
studied primarily in subunits <strong>of</strong><br />
tendons <strong>and</strong> ligaments small enough to<br />
transilluminate <strong>and</strong> not under<br />
functional loading conditions. Freezesubstitution<br />
fixation <strong>of</strong> tissues plungefrozen<br />
under load permits conventional<br />
polarized light <strong>and</strong> electron microscopy<br />
examination <strong>of</strong> collagen fibers<br />
preserved in a loaded state. This study<br />
examines whether the distribution <strong>of</strong><br />
strain can be mapped in loaded<br />
ligaments frozen in situ <strong>and</strong> fixed by<br />
freeze-substitution. In a second line <strong>of</strong><br />
investigation crimping behavior <strong>of</strong><br />
partially sectioned, loaded ligaments<br />
preserved by freeze-fixation was used<br />
to determine whether ligaments are<br />
Figure 1: Unloaded ligament- Crimped - 12X.<br />
composed <strong>of</strong> independent bundles <strong>of</strong><br />
interconnected fibrils. We hypothesized<br />
that (A) the crimping pattern <strong>of</strong> patellar<br />
ligaments under polarized light would<br />
progressively extinguish with increasing<br />
loads, <strong>and</strong> (B) that fibrils within a<br />
loaded “functional b<strong>and</strong>” would not<br />
recoil into a uniformly un-crimped<br />
state unless the entire b<strong>and</strong> is<br />
transected.<br />
METHODS AND MATERIALS<br />
Hind-limbs <strong>of</strong> 11 mature New<br />
Zeal<strong>and</strong> white rabbits sacrificed<br />
according to the ethical guidelines <strong>of</strong><br />
the local animal care committee were<br />
harvested, <strong>and</strong> the s<strong>of</strong>t tissues dissected<br />
leaving the femur- intact stifle joint<strong>and</strong><br />
tibia <strong>and</strong> extensor mechanism<br />
completely intact. The joint was fixed<br />
on to a frame while flexed at 90 o , <strong>and</strong> a<br />
simulated isometric quadriceps pull<br />
was applied by means <strong>of</strong> a wire passed<br />
through the patella, thus functionally<br />
loading the patellar ligament.<br />
Specimens were loaded at 9N (n=3),<br />
18N (n=3), 36N (n=3), 67N (n=3),<br />
100N (n=1), <strong>and</strong> 220N (n=1). After 30<br />
seconds a loaded joint was immersed<br />
in isopentane cooled to –165 0 C with<br />
liquid nitrogen. These knees <strong>and</strong> 2 unloaded<br />
control specimens were then<br />
fixed by freeze-substitution in<br />
methanol/acetone solutions <strong>of</strong> acrolein<br />
(-80 o C for 4 days) <strong>and</strong> glutaraldehyde<br />
(-20 o C for a further 4 days). Once<br />
brought to room temperature, the<br />
patellar ligaments were prepared for<br />
histological examination by paraffin<br />
embedding, 10um sectioning in the<br />
mid-sagittal plane <strong>and</strong> staining with<br />
Masson’s trichrome. The specimens<br />
were analyzed under polarized light<br />
microscopy, <strong>and</strong> the crimp pattern was<br />
analyzed by an observer blinded to the<br />
loading history. Based upon the relative<br />
amount <strong>of</strong> un-crimped tissue a<br />
speculation was recorded by the<br />
blinded observer as to whether no load,<br />
minimal load (9N), moderate load (18<br />
<strong>and</strong> 36N), or high load (>67N) was<br />
applied.<br />
Collagen Fiber Interaction<br />
Three specimens had a “deep”<br />
transverse scalpel cut made through the<br />
anterior b<strong>and</strong> <strong>of</strong> the patellar ligament<br />
at the mid-point. Three specimens had<br />
a“superficial” cut partially through the<br />
anterior b<strong>and</strong>. All these specimens were<br />
loaded at 150N. Two uncut controls<br />
were similarly loaded at 150N.<br />
Specimens were prepared for polarized<br />
light microscopy <strong>and</strong> scanning electron<br />
microscopy.<br />
RESULTS<br />
Unloaded ligaments displayed a<br />
consistent, regular pattern <strong>of</strong> crimp<br />
along the entire length <strong>of</strong> the specimens<br />
(Figure 1). The specimens loaded at 9<br />
Newtons were virtually<br />
indistinguishable from the unloaded<br />
specimens, with the exception <strong>of</strong> one<br />
specimen which had some uncrimping<br />
near the insertions. The specimens<br />
loaded at 18N had a b<strong>and</strong> <strong>of</strong> uncrimping<br />
in the central 1/3 <strong>of</strong> the<br />
ligament.<br />
The specimens loaded at 36 N had<br />
an increased area <strong>of</strong> un-crimping but<br />
crimping was still evident in the deep<br />
<strong>and</strong> superficial fibers <strong>of</strong> the ligaments<br />
32 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Figure 2: Loaded- 36 Newtons. Partial un-crimping- 12X.<br />
(Figure 2 <strong>and</strong> 3). The 67, 100, <strong>and</strong> 220<br />
N loaded specimens displayed no<br />
evidence <strong>of</strong> crimping in any region<br />
(Figure 4). The blinded observer<br />
correctly identified the loading history<br />
in 14/16 specimens. Two <strong>of</strong> the 9N<br />
loaded specimens were incorrectly<br />
identified as un-loaded specimens.<br />
Collagen Fiber Interaction<br />
Loading the uncut ligaments at<br />
150N resulted in complete un-crimping<br />
<strong>of</strong> the ligament. “Deep” section through<br />
the anterior 1/3 <strong>of</strong> the patellar ligament<br />
resulted in a crimping <strong>of</strong> the cut fibers<br />
which was visible to the full depth <strong>of</strong><br />
the incision, <strong>and</strong> which was visible from<br />
insertion to insertion (Figure 5). The<br />
uncut fibers immediately deep to the<br />
incision were loaded <strong>and</strong> completely<br />
un-crimped (Figure 5). The cut fibers<br />
at the deepest point <strong>of</strong> the incision were<br />
retracted to approximately the same<br />
distance as the superficial fibers.<br />
Superficial section, partially through<br />
the superficial b<strong>and</strong> <strong>of</strong> the patellar<br />
ligament, resulted in a localized<br />
retraction <strong>and</strong> crimping <strong>of</strong> fibers near<br />
the cut site (Figure 6). However, the cut<br />
fibers remained uncrimped along the<br />
majority <strong>of</strong> the length <strong>of</strong> the ligament.<br />
A triangular shaped lesion was visible<br />
on SEM, as the cut fibers adjacent to<br />
the loaded fibers were not as retracted,<br />
nor as crimped as the superficial cut<br />
fibers (Figure 7).<br />
Figure 3: Loaded- 36 Newtons. Partial un-crimping- 60X.<br />
Figure 4: Loaded- 67 Newtons. No Crimp 12X.<br />
DISCUSSION<br />
This study shows that freezefixation<br />
can preserve ligament collagen<br />
in an un-crimped state, <strong>and</strong> thus loaded<br />
fibers can be distinguished from nonloaded<br />
fibers in which a crimp remains.<br />
Using this technique, the rabbit patellar<br />
ligament showed a consistent pattern<br />
<strong>of</strong> strain dispersion with increasing<br />
load. Under these loading conditions,<br />
the central 1/3 <strong>of</strong> the ligament uncrimped<br />
at lower applied loads than the<br />
deep <strong>and</strong> superficial regions. The crimp<br />
in the entire specimen was extinguished<br />
at approximately 67N which, based<br />
upon ligament cross-sectional<br />
estimates, correlates closely with the<br />
previously reported toe-region <strong>of</strong> the<br />
stress strain curve <strong>of</strong> the rabbit patellar<br />
ligament (approx 4.5 MPa) (Woo et al,<br />
1993). The strength <strong>of</strong> this technique<br />
is that it enables investigators to<br />
examine entire ligaments or tendons<br />
preserved in a functionally loaded state<br />
using various forms <strong>of</strong> microscopy,<br />
including the potential use <strong>of</strong> high<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 33
Figure 5: Deep cut in loaded ligament. 12X.<br />
resolution electron microscopy.<br />
This study also confirms that the<br />
patellar ligament is composed <strong>of</strong><br />
independent parallel units. When<br />
transected, the anterior third <strong>of</strong> the<br />
ligament remains fully crimped even<br />
when the intact ligament is under<br />
sufficient tension to completely ablate<br />
crimp. This condition would not occur<br />
in the face <strong>of</strong> any functional crossover<br />
between cut <strong>and</strong> uncut segments. It<br />
also strongly implies that mechanical<br />
coupling between collagen fibrils does<br />
exist within the anterior b<strong>and</strong>, since<br />
partial section <strong>of</strong> that segment does not<br />
cause full recoil <strong>of</strong> the transected part.<br />
Collagen fiber recruitment is thought<br />
to be important to how ligaments resist<br />
elongation under load. This evidence<br />
for lateral support between collagen<br />
fibers further advances our<br />
underst<strong>and</strong>ing <strong>of</strong> the functional ultrastructure<br />
<strong>of</strong> normal ligaments.<br />
RECOMMENDED READING<br />
Gathercole <strong>and</strong> Keller, Matrix, 1991<br />
Woo et al. J. Orthop Res., 1993<br />
Figure 6: Superficial cut in loaded ligament. 60X.<br />
Figure 7: SEM superficial cut in loaded ligament.<br />
34 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
The Quality <strong>of</strong> Life Outcomes Following Total Shoulder<br />
Arthroplasty are Comparable to Those <strong>of</strong> Total Hip Arthroplasty<br />
<strong>and</strong> Coronary Artery Bypass Grafting<br />
RICHARD S. BOORMAN, M.D., M.SC., BRANKO KOPJAR, M.D., PH.D., EDWARD FEHRINGER, M.D.,<br />
R. SEAN CHURCHILL, M.D., KEVIN L. SMITH, M.D., AND FREDERICK A. MATSEN III, M.D.<br />
Arthritis <strong>of</strong> the shoulder can<br />
substantially compromise a<br />
patient’s general health status<br />
(Matsen et al, 2000). The goal <strong>of</strong> an<br />
arthroplasty is to improve not only the<br />
function <strong>of</strong> the joint, but also the<br />
patient’s overall health <strong>and</strong> well being.<br />
Health-related quality <strong>of</strong> life, selfassessment<br />
questionnaires have been<br />
used to document these results (Hozak<br />
et al, 1997). The Medical Outcomes<br />
Study Short-Form 36 (SF-36)<br />
questionnaire is particularly useful in<br />
this regard <strong>and</strong> has been used<br />
extensively in various patient groups<br />
(Ware, 1993). This questionnaire has<br />
been tested for validity <strong>and</strong> reliability,<br />
<strong>and</strong> population control results are<br />
published.<br />
Total shoulder arthroplasty (TSA)<br />
is the procedure <strong>of</strong> choice for managing<br />
patients with advanced glenohumeral<br />
osteoarthritis, however the degree to<br />
which shoulder arthroplasty improves<br />
the longer-term quality <strong>of</strong> life remains<br />
undefined. Furthermore, the relative<br />
effectiveness <strong>of</strong> shoulder arthroplasty in<br />
comparison to other common surgical<br />
interventions is unknown.<br />
The purpose <strong>of</strong> this study was (1)<br />
to evaluate the impact <strong>of</strong> TSA on the<br />
SF-36 in patients with glenohumeral<br />
osteoarthritis several years after surgery,<br />
(2) to compare the SF-36 scores for<br />
patients before <strong>and</strong> after TSA to those<br />
from a control population, <strong>and</strong> (3) to<br />
compare the results <strong>of</strong> TSA to the<br />
results <strong>of</strong> other effective orthopaedic<br />
<strong>and</strong> cardiac surgical procedures.<br />
METHODS AND MATERIALS<br />
One hundred <strong>and</strong> thirteen patients<br />
with primary glenohumeral<br />
osteoarthritis were treated with<br />
primary total shoulder arthroplasty<br />
(TSA) by an individual surgeon (FAM)<br />
between January 1, 1993 <strong>and</strong> December<br />
31, 1997. All patients completed the SF-<br />
36 before surgery, <strong>and</strong> at 6-month<br />
intervals post-operatively. Eighty-five<br />
patients were men <strong>and</strong> twenty-seven<br />
were women. Thirteen patients (12%)<br />
underwent bilateral total shoulder<br />
arthroplasties during that time. For<br />
these thirteen patients only the<br />
information related to the first operated<br />
shoulder was included in the analysis.<br />
A total <strong>of</strong> ninety-one patients had<br />
followup SF-36 data collected during<br />
the 30-60 month time frame after<br />
surgery. The mean <strong>of</strong> the 6 monthly<br />
interval scores for each dimension,<br />
reported in the 30-60 month time<br />
window, for each patient, was used as<br />
the post-operative score for statistical<br />
comparison.<br />
Postoperative values for SF-36<br />
dimensions were compared with<br />
preoperative values by using a paired<br />
t-test. Further, patients’ SF-36 scores<br />
were compared by paired t-test to those<br />
<strong>of</strong> age- <strong>and</strong> gender-matched general<br />
population controls reported in the<br />
literature. All analyses were performed<br />
using SPSS 10.0 for Windows.<br />
A Medline search was performed to<br />
find articles that report SF-36 results<br />
both pre-operatively <strong>and</strong> postoperatively,<br />
<strong>and</strong> at least one year<br />
following total hip replacement <strong>and</strong><br />
coronary bypass procedures. The<br />
average score weighted by sample size<br />
for each dimension from all studies that<br />
met our inclusion criteria were then<br />
calculated for both the THA patients<br />
<strong>and</strong> the CABG patients. These<br />
weighted average scores were compared<br />
to the TSA data from this study.<br />
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Physical<br />
Function<br />
Social<br />
Function<br />
Physical<br />
Role<br />
Emotional<br />
Role<br />
Mental<br />
Health<br />
Preoperative<br />
Postoperative<br />
Controls<br />
Energy Comfort General<br />
Health<br />
Figure 1: Preoperative <strong>and</strong> postoperative SF-36 scores for total shoulder arthroplasty compared age<strong>and</strong><br />
gender-matched data from control populations.<br />
RESULTS<br />
The average age <strong>of</strong> the patients in<br />
the study group was 64 years (S.D. = 10<br />
years), 62 years (S.D. = 10 years) among<br />
the seventy-two men <strong>and</strong> 73 years (S.D.<br />
= 7 years) among the nineteen women<br />
(p < .01). The ninety-one patients for<br />
whom 30-60 month followup data were<br />
available were not significantly different<br />
from the 22 patients for whom data in<br />
this time window were not available<br />
with respect to age, gender, or<br />
preoperative health status. Patients<br />
improved statistically significantly in<br />
the following SF-36 dimensions:<br />
physical role function (p
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Figure 2: Preoperative <strong>and</strong> postoperative SF-36 scores for total shoulder arthroplasty compared to<br />
weighted means for total hip arthroplasty reported in the literature.<br />
general health perception). These<br />
differences were statistically significant.<br />
After the surgery, although the amount<br />
<strong>of</strong> difference was much smaller, the<br />
scores for patients were still lower than<br />
population controls for most SF-36<br />
dimensions (Figure 1). Preoperatively,<br />
TSA patients scored higher than THA<br />
patients on all SF-36 dimensions.<br />
Postoperatively, there was little<br />
difference between the TSA <strong>and</strong> the<br />
THA patients (Figure 2). Similarly, the<br />
TSA patients scored higher than the<br />
CABG patients in all SF-36 dimensions<br />
TSA pre-op<br />
TSA post-op<br />
THA pre-op<br />
THA post-op<br />
TSA pre-op<br />
TSA post-op<br />
CABG pre-op<br />
CABG post-op<br />
Figure 3: Preoperative <strong>and</strong> postoperative SF-36 scores for total shoulder arthroplasty compared to<br />
weighted means for coronary bypass graft procedures reported in the literature.<br />
preoperatively. After surgery, the TSA<br />
patients scored better or equal to the<br />
CABG patients (Figure 3).<br />
DISCUSSION<br />
The patients in this study<br />
experienced significant improvements<br />
in their health- related quality <strong>of</strong> life<br />
following TSA for glenohumeral<br />
osteoarthritis. These improvements in<br />
multiple dimensions <strong>of</strong> the SF-36 were<br />
durable, since these gains were<br />
documented between 30 <strong>and</strong> 60<br />
months postoperatively. This study also<br />
documents the diminished quality <strong>of</strong><br />
life <strong>of</strong> individuals coming to surgery for<br />
glenohumeral osteoarthritis. In six out<br />
<strong>of</strong> eight SF-36 dimensions, the<br />
preoperative SF-36 scores for these<br />
patients was significantly lower than<br />
that <strong>of</strong> age- <strong>and</strong> gender-matched<br />
population controls. These scores<br />
improved after surgery, but did not<br />
reach the levels found in the control<br />
population (Radosevich et al, 1994).<br />
As increasing attention is focused<br />
on health care costs, the value <strong>of</strong><br />
surgical interventions to the patient <strong>and</strong><br />
the relative value <strong>of</strong> these procedures<br />
need to be well documented. In this<br />
spirit, we compared the changes in<br />
patient health status following TSA to<br />
the previously reported changes in<br />
quality <strong>of</strong> life following total hip<br />
arthroplasty, which is considered to be<br />
a very effective procedure. We observed<br />
that the SF-36 scores for patients with<br />
arthritis <strong>of</strong> the hip were lower than<br />
those <strong>of</strong> patients with shoulder<br />
arthritis. Postoperatively, both<br />
reconstructive procedures (total<br />
shoulder <strong>and</strong> total hip) demonstrated<br />
a similar effectiveness in improving<br />
quality <strong>of</strong> life.<br />
We also compared our results to<br />
another chronic medical condition<br />
which affects patients <strong>of</strong> a similar age,<br />
<strong>and</strong> for which the surgical solution is<br />
generally believed to be very effective:<br />
coronary artery bypass graft surgery.<br />
Patients with shoulder osteoarthritis<br />
appeared to score generally lower on the<br />
comfort score than those patients with<br />
chronic angina. In the other six healthrelated<br />
quality <strong>of</strong> life dimensions<br />
however, the patients with<br />
glenohumeral osteoarthritis tended not<br />
to score as low as the chronic angina<br />
patients did preoperatively.<br />
Postoperatively however, the total<br />
shoulder patients, <strong>and</strong> the CABG<br />
patients were brought up to similar<br />
levels for all eight SF-36 dimensions.<br />
In conclusion, this study has shown<br />
that total shoulder arthroplasty can<br />
improve the quality <strong>of</strong> life in patients<br />
with glenohumeral osteoarthritis<br />
several years after surgery.<br />
Postoperative SF-36 scores were lower<br />
than the control population, but they<br />
were similar to those previously<br />
reported for other effective orthopaedic<br />
<strong>and</strong> cardiac procedures.<br />
36 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
RECOMMENDED READING<br />
Hozack WJ, Rothman RH, Albert TJ,<br />
Balderston RA, et al. Relationship <strong>of</strong><br />
total hip arthroplasty outcomes to other<br />
orthopaedic procedures. Clin Orthop<br />
1997;(344):88-93.<br />
Matsen III FA, Antoniou J, Rozencwaig<br />
R, Campbell B, et al. Correlates with<br />
comfort <strong>and</strong> function after total<br />
shoulder arthroplasty for degenerative<br />
joint disease. J Shoulder Elbow Surg<br />
2000;9(6):465-9.<br />
Radosevich DM, Wetzler H, Wilson SM.<br />
Health Status Questionnaire (HSQ)<br />
2.0: scoring comparisons <strong>and</strong> reference<br />
data. Bloomington, MN: Health<br />
Outcomes Institute, 1994.<br />
Ware JE, Jr. SF-36 Health Survey:<br />
Manual <strong>and</strong> interpretation guide. The<br />
Health Institute, New Engl<strong>and</strong> Medical<br />
Center , Boston, MA , 1993.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 37
Less is More: Building Bigger <strong>Bone</strong>s With Less Exercise<br />
SUNDAR SRINIVASAN, PH.D., DAVID A. WEIMER, STEVEN C. AGANS, STEVEN D. BAIN,<br />
AND TED S. GROSS, PH.D.<br />
Deficient bone mass in the<br />
elderly arises due to<br />
degradation <strong>of</strong> the normal<br />
balance between bone resorption (i.e.,<br />
removal) <strong>and</strong> bone formation(i.e., new<br />
bone growth) typical in the young<br />
adult. Current pharmaceutical<br />
strategies to counteract bone loss are<br />
highly successful in blocking the<br />
elevated resorption associated with<br />
menopause. However, options for<br />
enhancing bone formation as a means<br />
<strong>of</strong> increasing bone mass are extremely<br />
limited. Given our rapidly aging<br />
population, the current inability to<br />
safely <strong>and</strong> effectively build bone mass<br />
consigns millions to a fate <strong>of</strong> elevated<br />
fracture risk for a substantial portion<br />
their lives.<br />
Exercise represents one <strong>of</strong> the few<br />
potential means <strong>of</strong> building bone mass.<br />
To date, however, exercise regimens<br />
have proven only minimally successful<br />
in building bone mass. The elderly, in<br />
particular, are unable to consistently<br />
comply with the high-impact,<br />
strenuous loading events (such as<br />
jumping <strong>and</strong> vigorous running)<br />
typically associated with even minimal<br />
bone accretion. One objective <strong>of</strong> our<br />
group has been to develop low<br />
magnitude loading regimens that are<br />
highly stimulatory for bone formation.<br />
Based on data from our group <strong>and</strong><br />
others, it appears that fluid flow within<br />
the tissue underlies bone<br />
mechanotransduction. We therefore<br />
hypothesized that inserting a nonloaded<br />
rest pause between each loading<br />
cycle (which would increase fluid flow<br />
within bone) would enhance the<br />
osteogenic potential <strong>of</strong> a low<br />
magnitude, locomotion-like<br />
mechanical loading regimen. To<br />
examine this hypothesis, we contrasted<br />
the ability <strong>of</strong> low magnitude loading<br />
regimens with <strong>and</strong> without a 10-s rest<br />
interval inserted between each load<br />
cycle to induce bone formation.<br />
METHODS<br />
Eighteen adolescent female C57Bl/<br />
6J mice (10 wk) underwent external<br />
loading <strong>of</strong> the right tibia using the noninvasive<br />
murine tibia loading device.<br />
Mice were r<strong>and</strong>omly assigned to three<br />
groups: 1) low magnitude (low; n=6),<br />
2) low magnitude, rest-inserted (restinserted,<br />
n=6), <strong>and</strong> 3) high magnitude<br />
(high, n=6). The low magnitude group<br />
underwent 100 cycle/d <strong>of</strong> a 0.25 N peak<br />
load, 1 Hz, 0.01/s strain rate trapezoidal<br />
waveform for 5 consecutive days<br />
(roughly equivalent to walking). The<br />
(A)<br />
(B)<br />
(C)<br />
Figure 1: Composite fluorescent<br />
micrographs <strong>of</strong> the mouse mid-shaft<br />
illustrate minimal periosteal bone<br />
formation in response to the low<br />
magnitude regimen (A), <strong>and</strong> substantial<br />
periosteal bone formation stimulated by<br />
the high magnitude (B) <strong>and</strong> rest-inserted<br />
regimens (C, arrows). Endocortical<br />
labeling was similar for each group <strong>and</strong><br />
no different than that observed in intact,<br />
contralateral tibia.<br />
low magnitude rest-inserted group<br />
underwent a 10 cycle/d regime with a<br />
10 s pause inserted between each load<br />
cycle. Peak load <strong>and</strong> peak strain rate<br />
were equivalent to the low magnitude<br />
group. The high magnitude group<br />
underwent a 100 cycle/d, 1 Hz regime<br />
with the peak load <strong>and</strong> strain rate<br />
doubled compared to the low<br />
magnitude group (roughly equivalent<br />
to vigorous running). The overall daily<br />
external loading period for the mice in<br />
all groups was therefore 100 s. All<br />
animals were allowed 23 d <strong>of</strong> additional<br />
cage activity following the 5 day loading<br />
regimen to facilitate consolidation <strong>of</strong><br />
new bone. <strong>Bone</strong> formation was<br />
assessed via dynamic<br />
histomorphometry.<br />
RESULTS<br />
Consistent with normal long bone<br />
growth, the young mice examined in<br />
this study exhibited active osteoblast<br />
activity on both endocortical <strong>and</strong><br />
periosteal surfaces at the initiation <strong>of</strong><br />
the study. Periosteal bone formation<br />
rate was significantly elevated by both<br />
high magnitude (p=0.01; 3.7-fold vs<br />
paired contralateral tibia) <strong>and</strong> restinserted<br />
loading (p=0.01; 2.3-fold vs<br />
paired contralateral tibia; Figures 1, 2).<br />
While high magnitude <strong>and</strong> restinserted<br />
loading were more stimulatory<br />
for osteoblasts than low magnitude<br />
loading, no statistical differences were<br />
observed between high magnitude <strong>and</strong><br />
rest-inserted loading with any assessed<br />
bone formation parameter. As<br />
compared to intact bones, both high<br />
magnitude (p=0.05) <strong>and</strong> rest-inserted<br />
(p=0.03) loading induced small, but<br />
significant increases in cortical area (5.1<br />
<strong>and</strong> 6.2%, respectively).<br />
DISCUSSION<br />
Using the non-invasive murine tibia<br />
loading model, we found that low<br />
magnitude, rest-inserted loading<br />
significantly enhanced periosteal bone<br />
formation in growing mice.<br />
Surprisingly, the bone formation<br />
elicited by 10 cycles <strong>of</strong> rest-inserted<br />
loading was statistically comparable to<br />
that induced by a st<strong>and</strong>ard locomotionlike<br />
waveform 10-fold greater in cycle<br />
38 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Ps.BFR (µ m 3 /µ m 2 /d)<br />
0.6<br />
0.4<br />
0.2<br />
* ^<br />
* ^<br />
INTACT<br />
EXP<br />
0<br />
LOW HIGH REST<br />
Figure 2: Periosteal bone formation parameters at the tibia mid-shaft in response to low, high, <strong>and</strong> rest-inserted loading. Low magnitude loading did not<br />
significantly alter mineralizing surface (A), mineral apposition rate (B), or bone formation rate (C) compared to intact contralateral tibia. Both high<br />
magnitude <strong>and</strong> rest-inserted loading significantly enhanced these parameters (*). High magnitude <strong>and</strong> rest-inserted loading induced significantly greater<br />
mineral apposition <strong>and</strong> bone formation compared to the low magnitude loading (^). For all each <strong>of</strong> the parameters, no statistical differences were<br />
observed when high magnitude <strong>and</strong> rest-inserted loading were contrasted.<br />
number <strong>and</strong> 2-fold greater in load<br />
magnitude. To our knowledge, this<br />
represents the first report <strong>of</strong> enhanced<br />
bone formation induced by a reduced<br />
mechanical stimulus.<br />
While rest-inserted loading remains<br />
to be optimized, it represents a<br />
departure from previous modalities <strong>of</strong><br />
repetitively loading bone tissue. In<br />
general, in vivo <strong>and</strong> in vitro<br />
investigations have established the<br />
paradigm that the greater the<br />
mechanical stimulus, the greater the<br />
response elicited from bone cells or<br />
bone tissue. Here, we found that 10<br />
cycles <strong>of</strong> rest inserted loading<br />
substantially enhanced bone formation<br />
compared to 100 cycles <strong>of</strong> an identical<br />
magnitude repetitive protocol.<br />
Surprisingly, the amount bone<br />
formation was not significantly<br />
different then that achieved with a<br />
group exposed to twice the load<br />
magnitude <strong>and</strong> rate <strong>and</strong> ten times the<br />
number <strong>of</strong> load cycles. The ability <strong>of</strong><br />
rest-inserted loading to induce more<br />
(or equivalent) bone formation with<br />
less actual loading <strong>of</strong> bone directly<br />
challenges the concept that high<br />
magnitude, high impact loading is<br />
required to build bone mass.<br />
In this context, the broad relevance<br />
<strong>of</strong> these data lie with their potential to<br />
substantially extend the skeletal benefits<br />
<strong>of</strong> mild exercise. The ability to induce<br />
bone formation in growing or mature<br />
skeletons via low magnitude, nonimpact<br />
loading would make bone<br />
building exercise accessible to all ages<br />
while minimizing injury risk. A<br />
number <strong>of</strong> possibilities might be readily<br />
explored to implement rest-inserted<br />
loading. Tai Chi, which has already<br />
been suggested to enhance balance in<br />
the elderly, might be modified such that<br />
postures between movements are<br />
deliberately held for longer periods <strong>of</strong><br />
time. Similarly, small h<strong>and</strong> weights<br />
might be held in fixed positions<br />
between each repetition to enhance<br />
bone mass in the upper extremities.<br />
With such ease <strong>of</strong> implementation, restinserted<br />
waveforms might also serve to<br />
beneficially modify the locomotion<br />
related loading that has proven to be <strong>of</strong><br />
limited effectiveness in inhibiting space<br />
induced bone loss.<br />
RECOMMENDED READING<br />
Hosking D, Chilvers CED, Christiansen<br />
C, Ravn P, Wasnich R, Ross P, McClung<br />
M, Balske A, Thompson D, Daley M,<br />
Yates AJ 1998 Prevention <strong>of</strong> <strong>Bone</strong> Loss<br />
with Alendronate in Postmenopausal<br />
Women under 60 Years <strong>of</strong> Age. N Engl<br />
J Med 338(8):485-92.<br />
Nelson ME, Fiatarone MA, Morganti<br />
CM, Trice I, Greenberg RA, Evans WJ<br />
1994 Effects <strong>of</strong> high-intensity strength<br />
training on multiple risk factors for<br />
osteoporotic fractures. A r<strong>and</strong>omized<br />
controlled trial. Jama 272(24):1909-14.<br />
Gross TS, Srinivasan S, Liu C, Clemens<br />
TL, Bain SD in press Non-invasive<br />
loading <strong>of</strong> the murine tibia: an in vivo<br />
model for study <strong>of</strong><br />
mechanotransduction. J <strong>Bone</strong> Miner<br />
Res.<br />
Wolfson L, Whipple R, Derby C, Judge<br />
J, King M, Amerman P, Schmidt J,<br />
Smyers D 1996 Balance <strong>and</strong> strength<br />
training in older adults: intervention<br />
gains <strong>and</strong> Tai Chi maintenance [see<br />
comments]. J Am Geriatr Soc<br />
44(5):498-506.<br />
Baldwin KM, White TP, Arnaud SB,<br />
Edgerton VR, Kraemer WJ, Kram R,<br />
Raab-Cullen D, Snow CM 1996<br />
Musculoskeletal adaptations to<br />
weightlessness <strong>and</strong> development <strong>of</strong><br />
effective countermeasures. Med Sci<br />
Sports Exerc 28(10):1247-53.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 39
Evidence that FGF-18 is a Growth Factor for Mature Human<br />
Articular Chondrocytes<br />
RUSSELL J. FERNANDES, PH.D., JEFF L. ELLSWORTH, PH.D., EMMA E. MOORE, PH.D.,<br />
STEVEN D. HUGHES, PH.D., AND DAVID R. EYRE, PH.D.<br />
Articular cartilages are specialized<br />
connective tissues that dissipate<br />
loads as the bearing surfaces in<br />
joints. Cartilage cells, the chondrocytes,<br />
synthesize a complex extracellular<br />
matrix containing collagens,<br />
proteoglycans, <strong>and</strong> noncollagenous<br />
proteins. Type II collagen, the<br />
predominant collagen <strong>of</strong> cartilage is<br />
polymerized into a network <strong>and</strong> is<br />
responsible for the tensile strength <strong>of</strong><br />
cartilage.<br />
Trauma <strong>and</strong> disease <strong>of</strong> the synovial<br />
joint can cause structural damage to the<br />
articular cartilage. Changes include<br />
age-related fibrillation, cartilage<br />
degeneration due to osteoarthritis, <strong>and</strong><br />
focal chondral <strong>and</strong> osteochondral<br />
defects. In most other tissues, such<br />
lesions would be rapidly repaired.<br />
Adult articular cartilage, however, has<br />
only a very limited capacity to heal.<br />
Efforts to stimulate cartilage healing<br />
have focussed on two general areas:<br />
surgical procedures, designed to<br />
stimulate the endogenous repair<br />
response, <strong>and</strong> biological repair,<br />
designed to stimulate chondrocyte<br />
proliferation <strong>and</strong>/or matrix production<br />
by the application <strong>of</strong> peptide growth<br />
factors or by cell transplantation.<br />
The fibroblast growth factors<br />
(FGF’s) play roles in tissue repair,<br />
embryonic development, <strong>and</strong> growth in<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
FGF18<br />
Figure 1: Effect <strong>of</strong> FGF-18 on chondrocyte proliferation.<br />
animals. FGF-18, a novel member <strong>of</strong><br />
the FGF family has been shown to<br />
stimulate hepatocytes <strong>and</strong> intestinal<br />
cells to proliferate. As part <strong>of</strong> a screen<br />
for factors that regulate angiogenesis,<br />
we expressed Fgf18 by adenovirusmediated<br />
gene transfer in the pinnae <strong>of</strong><br />
nude mice. Although an angiogenic<br />
response was not observed, a surprising<br />
phenotype developed: compared to<br />
pinnae that received null adenovirus,<br />
those that received adenovirusexpressing<br />
Fgf18 became visibly thicker.<br />
The increase in thickness was largely<br />
due to an Fgf18-mediated increase in<br />
chondrocyte proliferation, type-II<br />
collagen synthesis, <strong>and</strong> extracellular<br />
matrix production.<br />
These interesting observations<br />
prompted us to investigate if Fgf18 was<br />
expressed by articular chondrocytes<br />
<strong>and</strong> examine the effects <strong>of</strong> highly<br />
purified FGF-18 protein on articular<br />
chondrocytes in vivo <strong>and</strong> vitro. Our<br />
results suggest that Fgf18 may play a<br />
role in the biology <strong>of</strong> normal cartilage.<br />
METHODS<br />
Cell <strong>and</strong> tissue culture<br />
Full thickness adult human<br />
cartilage, <strong>and</strong> chondrocytes (high<br />
density monolayer or micromass)<br />
isolated from talus joints (Northwest<br />
Tissue Center, Seattle) were maintained<br />
+FGF18<br />
Control<br />
0 1 2 3 4 5 6<br />
Week in culture<br />
in serum free culture (DMEM) in the<br />
presence or absence <strong>of</strong> 100ng/ml<br />
recombinant FGF-18 protein. Cell<br />
numbers from monolayer cultures were<br />
determined weekly with the aid <strong>of</strong> a<br />
Neubauer haemocytometer. Cell layer<br />
collagen from monolayer or micromass<br />
cultures was solubilized by pepsin<br />
digestion <strong>and</strong> the a1(II)chains were<br />
identified by western blotting after<br />
SDS-PAGE.<br />
Histochemistry<br />
<strong>and</strong><br />
Immunohistochemistry<br />
Micromass cultures were fixed,<br />
embedded in paraffin, sectioned <strong>and</strong><br />
stained with saffranin O, H&E <strong>and</strong><br />
immunostained with type II collagen<br />
antibody <strong>and</strong> proliferating cell nuclear<br />
antigen (PCNA) antibody.<br />
RESULTS AND DISCUSSION<br />
In situ hybridizations revealed that<br />
Fgf18 mRNA <strong>and</strong> mRNA for two <strong>of</strong> its<br />
receptors, Fgfr3-(IIIc) <strong>and</strong> Fgfr2-(IIIc),<br />
were localized within chondrocytes <strong>of</strong><br />
human talus articular cartilage.<br />
Incubation <strong>of</strong> primary cultures <strong>of</strong><br />
adult human talus articular<br />
chondrocytes with FGF-18 protein<br />
increased the proliferation <strong>of</strong> these cells<br />
(Figure 1).<br />
Western blot analysis <strong>of</strong> collagen<br />
deposited in the extracellular matrix<br />
showed an increase in type II collagen<br />
accumulation within one week after<br />
culture in the presence <strong>of</strong> FGF18<br />
(Figure 2).<br />
In high-density micromass cultures,<br />
(Figure 3) the thickness <strong>of</strong> the cell layer,<br />
cell numbers, staining <strong>of</strong> chondrocyte<br />
nuclei with antibodies to proliferating<br />
cell nuclear antigen (PCNA) (Figure 3,<br />
panels B, D) <strong>and</strong> type II collagen<br />
accumulation in the extracellular<br />
matrix (Figure 3, panels A, C) were<br />
increased by incubation with media<br />
containing 100ng FGF-18/ml for 4<br />
weeks. Increased PCNA staining was<br />
also seen in the nuclei <strong>of</strong> chondrocytes<br />
from explant cultures treated with FGF-<br />
18 (data not shown).<br />
These data imply that FGF-18 can<br />
act as a trophic factor for adult human<br />
articular chondrocytes in primary cell<br />
40 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Figure 2: Western blot showing type II collagen deposition.<br />
culture <strong>and</strong> in explants. In addition,<br />
these data show that the differentiation<br />
state <strong>of</strong> the chondrocytes, as<br />
determined by type II collagen, was<br />
maintained by FGF-18 under these<br />
conditions. The expression <strong>of</strong> Fgf18<br />
<strong>and</strong> its receptors by chondrocytes in<br />
cartilage suggests that Fgf18 may play<br />
an autocrine role in the biology <strong>of</strong><br />
normal articular cartilage <strong>and</strong> could<br />
potentially be useful in stimulating<br />
chondrocytes to proliferate <strong>and</strong><br />
promote repair <strong>of</strong> damaged cartilages.<br />
RECOMMENDED READING<br />
Eyre DR, Muir H. The distribution <strong>of</strong><br />
different molecular species <strong>of</strong> collagen<br />
in fibrous, elastic <strong>and</strong> hyaline cartilages<br />
<strong>of</strong> the pig. Biochem J 1975;151:595-602.<br />
Frenkel SR, Di Cesare PE. Degradation<br />
<strong>and</strong> repair <strong>of</strong> articular cartilage. Front<br />
Biosci 1999;4:D671-85.<br />
Coutts RD, Sah RL, Amiel D. Effects <strong>of</strong><br />
growth factors on cartilage repair. Instr<br />
Course Lect 1997;46:487-94.<br />
Ornitz DM, Itoh N. Fibroblast growth<br />
factors. Genome Biol<br />
2001;2:REVIEWS3005.1-3005.12.<br />
Figure 3: Immunohistochemical staining <strong>of</strong> 4 week micromass cultures <strong>of</strong> human adult talus chondrocytes. Panels A, B, untreated; Panels C, D, FGF-18<br />
treated. Magnification 40X.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 41
Whitmore TE, Maurer MF, Sexson S,<br />
Raymond F, Conklin D, Deisher TA.<br />
Assignment <strong>of</strong> fibroblast growth factor<br />
18 (FGF18) to human chromosome<br />
5q34 by use <strong>of</strong> radiation hybrid<br />
mapping <strong>and</strong> fluorescence in situ<br />
hybridization. Cytogenet Cell Genet<br />
2000;90:231-3.<br />
Trippel SB. Growth factor actions on<br />
articular cartilage. J Rheumatol Suppl<br />
1995;43:129-32.<br />
42 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
A Newly Identified Site <strong>of</strong> Cross-Linking Between Collagens<br />
IX <strong>and</strong> II: Insights On Molecular Assembly In Cartilage<br />
JIANN-JIU WU, PH.D., TERRI A. PIETKA, B.S., MARY ANN WEIS, B.S., AND DAVID R. EYRE, PH.D.<br />
The collagenous framework <strong>of</strong><br />
articular cartilage matures from<br />
a covalently cross-linked<br />
heteropolymer <strong>of</strong> types II, IX <strong>and</strong> XI<br />
collagens (Figure 1). Type IX collagen<br />
is a quantitatively minor component <strong>of</strong><br />
the adult tissue but it has an important<br />
role in the assembly <strong>and</strong> function <strong>of</strong> the<br />
matrix. In cartilage, type IX collagen<br />
molecules are bound to the surface <strong>of</strong><br />
type II collagen fibrils <strong>and</strong> to each other<br />
via lysine-derived cross-links.<br />
Mutations in type IX collagen genes can<br />
cause multiple epiphyseal dysplasia in<br />
which the cartilage collagen fibrils<br />
appear abnormal <strong>and</strong> show evidence <strong>of</strong><br />
a deficiency in intermolecular crosslinking<br />
<strong>of</strong> type IX collagen. The type<br />
IX collagen molecule is a heterotrimer<br />
<strong>of</strong> α1(IX), α2(IX), <strong>and</strong> α3(IX) chains.<br />
Each chain contains three relatively<br />
short triple helical domains (COL1-3)<br />
<strong>and</strong> four noncollagenous domains<br />
(NC1-4). The three chains are linked<br />
intramolecularly by disulfide bonds in<br />
the NC1 <strong>and</strong> NC3 domains.<br />
When analyzing the pepsinsolubilized<br />
type II collagen from bovine<br />
<strong>and</strong> human cartilages on SDS-PAGE by<br />
Western blotting, we consistently<br />
observed a minor fraction <strong>of</strong> type II<br />
collagen in a disulfide bonded complex.<br />
By further characterization <strong>of</strong> the<br />
protein, we revealed a previously<br />
unrecognized <strong>and</strong> prominent<br />
intermolecular cross-linking site<br />
between collagen types II <strong>and</strong> IX.<br />
MATERIALS AND METHODS<br />
Slices <strong>of</strong> fetal human <strong>and</strong> fetal<br />
bovine epiphyseal cartilage were<br />
extracted at 4°C in 4M guanidine HCl<br />
for 24 h to remove non-cross-linked<br />
matrix proteins <strong>and</strong> proteoglycans. The<br />
washed residues were minced <strong>and</strong><br />
digested with pepsin <strong>and</strong> salt<br />
fractionated into types II, IX <strong>and</strong> XI<br />
collagens. Type II collagen was resolved<br />
on a BioRad A5m agarose molecular<br />
sieve column. Protein fractions were<br />
assayed by SDS-PAGE <strong>and</strong> transblotted<br />
to PVDF membrane for either Western<br />
blot analysis or amino-terminal protein<br />
sequence analysis. CNBr digestion was<br />
carried out in 70% formic acid at room<br />
temperature for 24 hr. Peptides<br />
containing the α1(IX)NC1 sequence<br />
were purified by a mAb 2B4 affinity<br />
column, followed by reverse-phase<br />
HPLC on a C8 column. Purified<br />
peptides were analyzed by Western<br />
blotting with a mAb 2B4. For aminoterminal<br />
sequence analysis, protein<br />
b<strong>and</strong>s were transblotted to PVDF<br />
membrane <strong>and</strong> analyzed <strong>and</strong> identified<br />
by amino-terminal microsequencing<br />
on a Porton 2090E gas phase sequencer<br />
equipped with on-line HPLC analysis<br />
<strong>of</strong> PTH-derivatives.<br />
Figure 1: Molecular diagram showing the cartilage collagen heteropolymeric fibril <strong>and</strong> sites <strong>of</strong> covalent<br />
interactions.<br />
RESULTS AND DISCUSSION<br />
Pepsin-extracted type II collagen<br />
from fetal bovine epiphyseal cartilage<br />
was fractionated on an agarose<br />
molecular sieve column. Analysis <strong>of</strong><br />
protein across the chromatogram by<br />
SDS-PAGE revealed a higher molecular<br />
weight (150 kDa) fraction <strong>of</strong> type II<br />
collagen that appeared to be disulfide<br />
bonded. After disulfide bond cleavage<br />
with DTT, the reduced product<br />
migrated slightly slower than the α1(II)<br />
chain (Figure 2). Both the non-reduced<br />
<strong>and</strong> reduced b<strong>and</strong>s were recognized by<br />
antibodies to type II collagen. N-<br />
terminal protein microsequencing <strong>of</strong><br />
the reduced b<strong>and</strong> after transblotting to<br />
a PVDF membrane gave two running<br />
sequences.<br />
One,<br />
GVMQGPMGPMGPRGPP*, matches<br />
the N-terminus <strong>of</strong> the main triple<br />
helical domain <strong>of</strong> the type II collagen<br />
molecule, while the other,<br />
LKRPDSGASGLP*GRP*G, matches a<br />
sequence in the COL1 domain <strong>of</strong><br />
pepsin-derived bovine α1(IX). The<br />
results indicate, therefore, that the<br />
parent fragment was α1(IX)COL1<br />
linked covalently to the triple-helix <strong>of</strong><br />
an α1(II) chain. The equivalent<br />
disulfide-bonded entity was also<br />
identified in digests <strong>of</strong> fetal human<br />
cartilage.<br />
In addition to binding to antibodies<br />
against a triple-helical epitope in type<br />
II collagen, the human protein also<br />
reacted with monoclonal antibody 2B4.<br />
Monoclonal antibody 2B4 was<br />
originally developed <strong>and</strong> used to detect<br />
a proteolytic cleavage product <strong>of</strong> a<br />
Proline/Leucine bond in the α1(II) C-<br />
telopeptide found in cartilage <strong>and</strong> body<br />
fluids. The epitope recognized by the<br />
antibody is the -EKGPDP sequence, in<br />
which the C-terminal proline is<br />
essential for immunoreactivity.<br />
Coincidentally, the antibody also reacts<br />
with intact human α1(IX) chains,<br />
which end in a similar sequence,<br />
NKGPDP at the C-terminus. Therefore,<br />
we used 2B4 antibody to track peptide<br />
fragments that contained the –KGPDP<br />
sequence. Conversely, bovine α1(IX)<br />
lacks this sequence it does not react<br />
with 2B4.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 43
Figure 2: Electrophoresis <strong>of</strong> molecular sieve fractionated type II collagen from fetal bovine epiphyseal<br />
cartilage on SDS-5% PAGE. Collagen samples were run under non-reducing <strong>and</strong> reducing conditions.<br />
Arrows show the type II collagen fraction that appears to be disulfide bonded. The reduced protein<br />
was blotted to PVDF membrane <strong>and</strong> identified by N-terminal sequence analysis.<br />
To define precisely the sites <strong>of</strong><br />
intermolecular cross-linking, a mAb<br />
2B4 affinity column was used to purify<br />
cross-linked CB peptides that<br />
contained α1(IX)NC1 from a CB digest<br />
<strong>of</strong> human type II collagen. A<br />
methionine in this domain ensures its<br />
release as a short peptide. Peptides<br />
eluted from the affinity column were<br />
further purified by RP-HPLC then<br />
SDS-PAGE. Western blot analysis was<br />
performed with mAb 2B4.<br />
Amino-terminal sequence analysis<br />
<strong>of</strong> the purified peptide identified it as<br />
α1(IX)NC1 cross-linked to a helical site<br />
in α1(II) CB9,7, which most likely is the<br />
known 930 hydroxylysine cross-linking<br />
residue. The discovery <strong>of</strong> this domain<br />
<strong>of</strong> type IX collagen linked to the type II<br />
collagen triple helix was not predicted<br />
from earlier methods <strong>of</strong> finding as<br />
cross-linking sites in the collagen IX<br />
molecule (Figure 1). It was known that<br />
type IX collagen is extensively crosslinked<br />
in cartilage matrix through lysyl<br />
oxidase-mediated bonds to both N-<br />
<strong>and</strong> C- telopeptides <strong>of</strong> type II collagen<br />
<strong>and</strong> between the type IX collagen<br />
molecules themselves through the<br />
α3(IX)NC1 domain. The finding <strong>of</strong><br />
α1(IX)NC1 links to type II collagen,<br />
taken with other properties <strong>of</strong> fibril<br />
associated collagen molecules, suggest<br />
that the initial docking <strong>and</strong> crosslinking<br />
<strong>of</strong> type IX molecules on type II<br />
fibrils occurs through the COL1/NC1<br />
domain interacting with the hole region<br />
<strong>of</strong> the quarter-staggered assembly<br />
(Figure 3).<br />
RECOMMENDED READING<br />
Mendler M, Eich-Bender S G, Vaughan<br />
L, Winterhalter KH, Bruckner P. (1989)<br />
Cartilage contains mixed fibrils <strong>of</strong><br />
collagen types II, IX, <strong>and</strong> XI. J. Cell Biol.<br />
108, 191-197.<br />
Figure 3: Collagen IX / II cross-linking interactions: working model.<br />
Wu JJ, Woods P E, Eyre DR. (1992)<br />
Identification <strong>of</strong> cross-linking sites in<br />
bovine cartilage type IX collagen reveals<br />
an antiparallel type II-type IX<br />
molecular relationship <strong>and</strong> type IX to<br />
type IX bonding. J. Biol. Chem. 267,<br />
23007-23014.<br />
Diab M, Wu JJ, Eyre DR. (1996)<br />
Collagen type IX from human cartilage:<br />
a structural pr<strong>of</strong>ile <strong>of</strong> intermolecular<br />
cross-linking sites. Biochem. J. 314, 327-<br />
332.<br />
Bönnemann CG, Cox GF, Shapiro F, Wu<br />
JJ, Feener CA, Thompson T, Anthony<br />
DC, Eyre DR, Darras B, Kunkel LM.<br />
(2000) A mutation in the a3 chain <strong>of</strong><br />
type IX collagen causes autosomal<br />
dominant multiple epiphyseal dysplasia<br />
with mild myopathy. Proc. Natl. Acad.<br />
Sci. USA 97, 1212-1217.<br />
van der Rest M, Mayne R. (1989) Type<br />
IX collagen. In: Structure <strong>and</strong> Function<br />
<strong>of</strong> Collagen Types (Mayne R. <strong>and</strong><br />
Burgeson RE, eds.), pp. 195-221,<br />
Academic Press.<br />
Atley LM, Shao P, Ochs V, Shaffer K,<br />
Eyre DR. (1998) Matrix<br />
metalloproteinase-mediated release <strong>of</strong><br />
immunoreactive telopeptides from<br />
cartilage type II collagen. Trans.<br />
Orthop. Res. Soc., 23, 850.<br />
44 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Reproductive Hormone Effects on ACL Strength<br />
EMMA WOODHOUSE, M.D., PETER T. SIMONIAN, M.D., ALLAN F. TENCER, PH.D., AND PHIL HUBER, PH.D.<br />
In the United States there are<br />
approximately 100,000 ACL<br />
injuries annually, corresponding to<br />
one injury per 3000 individuals per<br />
year. Epidemiologic studies show that<br />
female athletes suffer 2 to 8 times more<br />
ACL injuries than their male<br />
counterparts. Many young women<br />
athletes take oral contraceptive pills for<br />
menstrual regulation, to decrease acne<br />
or dysmennorhea <strong>and</strong> for<br />
contraception. Cyclic fluctuations in<br />
estrogen levels have been implicated in<br />
the increased vulnerability <strong>of</strong> the female<br />
ACL, however no studies to date have<br />
investigated whether the hormonal<br />
milieu <strong>of</strong> normal menses vs oral<br />
contraceptive intake have differential<br />
effects on ACL response to stress. If<br />
there is a difference in their effect on<br />
the ACL, it could have important<br />
implications for female athletes <strong>of</strong> all<br />
levels.<br />
In our study we attempt to use a rat<br />
model <strong>of</strong> normal menstrual cycle <strong>and</strong><br />
oral contraceptive administration to<br />
investigate the chronic effect <strong>of</strong> two<br />
typical hormonal milieus on ACL<br />
collagen mechanics.<br />
METHODS<br />
Female rats undergo cyclic<br />
hormonal changes much like women<br />
only their cycle is 5 days in length rather<br />
than 28 days. 40 female Sprague-<br />
Dawley sexually mature rats (avg body<br />
weight 150g) were be obtained from a<br />
commercial laboratory. The rats were<br />
housed individually in cages <strong>and</strong> fed rat<br />
chow <strong>and</strong> water ad libidum. They were<br />
kept under st<strong>and</strong>ard conditions. The 40<br />
Table 1: Rat Hormone Levels.<br />
female rats were divided evenly into two<br />
experimental groups called M <strong>and</strong> O.<br />
All rats were kept for 60 days which<br />
corresponds to 12 oestrus cycles. The<br />
rats in group O were given oral<br />
contraceptive steroids dissolved in<br />
0.25ml propylene glycol orally by tube.<br />
The ethinylestradiol dose was 1.27ng.<br />
The levonorgestrel was 4.5ng. These<br />
doses were estimates <strong>of</strong> the rat<br />
equivalent dose <strong>of</strong> human oral<br />
contraceptive pills based on differential<br />
weight <strong>and</strong> bioavailability. The rats<br />
were given the combination steroid or<br />
placebo at the same time each day for 4<br />
days <strong>and</strong> then it was held for 1 day to<br />
simulate the pill free week in human<br />
OCP’s. After 40 days, 6 rats from each<br />
group were selected r<strong>and</strong>omly to<br />
undergo daily phlebotomy for 5 days<br />
(0.75cc blood per day.) The blood was<br />
sent on ice for estrogen <strong>and</strong><br />
progesterone levels at a commercial<br />
laboratory. At the end <strong>of</strong> 60 days, the<br />
rats were sacrificed in a CO2 chamber.<br />
One femur-ACL-tibia complex from<br />
each rat was then stripped <strong>of</strong> all s<strong>of</strong>t<br />
tissue <strong>and</strong> the bones potted in<br />
methylmethacrylate. The experiment<br />
began with 21 rats in the control group<br />
<strong>and</strong> 19 in the experimental group. One<br />
<strong>of</strong> the experimental rats died in week<br />
four so eighteen experimental rats <strong>and</strong><br />
twenty one control rat specimen were<br />
dissected. Two ACL’s from the<br />
experimental group <strong>and</strong> two from the<br />
control group were ruined during the<br />
potting process. One was dropped on<br />
the floor <strong>and</strong> broke while the other<br />
three had methylmethacrylate touch<br />
the ACL. These specimens were<br />
day 3 day 3 day 4 day 4 day 5 day 5<br />
estrogen estrogen progest progest progest progest<br />
exp control exp control exp control<br />
mean 17.27 33.74 2.49 16.6 8.67 23.67<br />
std dev 16.66 6.68 0.08 0.74 3.81 1.53<br />
t 2.2464 46.67 8.948<br />
d<strong>of</strong> 10 10 10 10 10 10<br />
p value
hormone level<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Experimental Rat Hormone Values<br />
1 2 3 4 5<br />
day<br />
while also increasing collagen<br />
degredation. Estrogen also increases<br />
collagen crosslinking, speeding the<br />
conversion <strong>of</strong> newly synthesized<br />
collagen to mature collagen. In post<br />
menopausal women, estrogen <strong>and</strong><br />
progesterone combined therapy at low<br />
doses decreases collagen type 1 while<br />
increasing type 3 collagen.<br />
Liu et al have done several studies<br />
investigating the role <strong>of</strong> female sex<br />
steroids on ACL tissue. In 1996 they<br />
demonstrated estrogen <strong>and</strong><br />
progesterone receptors on the ACL<br />
using immunohistochemical<br />
techniques. These receptors have also<br />
been localized on both human <strong>and</strong><br />
rabbit ACL by reverse Polymerase<br />
Chain Reaction. Liu et al also found<br />
that physiologic doses <strong>of</strong> estrogen have<br />
a dose dependent effect on rabbit ACL<br />
40<br />
30<br />
20<br />
10<br />
Figure A: Graph <strong>of</strong> Hormonal Milieu in the Experimental Group.<br />
hormone level<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Control Rat Hormone Values<br />
1 2 3 4 5<br />
day<br />
Figure B: Graph <strong>of</strong> Hormonal Milieu in the Control Group.<br />
0<br />
estrogen:<br />
pg/ml<br />
progesterone:<br />
ng/ml<br />
tissue reducing fibroblast proliferation<br />
<strong>and</strong> rate <strong>of</strong> collagen synthesis. In a<br />
follow up study, the group noted that<br />
the dose dependent effect <strong>of</strong> estrogen<br />
seen on days 1 through 3 was attenuated<br />
on days 7, 10 <strong>and</strong> 14 <strong>of</strong> treatment. Also,<br />
type 1 collagen synthesis was decreased<br />
but not type 3 collagen. Type 3 collagen<br />
synthesis remained unaffected by<br />
estrogen exposure. Type 1 collagen<br />
tends to impart mechanical strength to<br />
connective tissue while type 3 collagen<br />
is correlated with elasticity. The authors<br />
concluded that sudden or cumulative<br />
fluctuations in serum estrogen<br />
concentration may induce metabolic<br />
changes in ACL fibroblasts which<br />
would predispose the ligament to<br />
injury.<br />
Sciore et al demonstrated that<br />
estrogen <strong>and</strong> progesterone receptor<br />
40<br />
30<br />
20<br />
10<br />
0<br />
estrogen:<br />
pg/ml<br />
progesterone:<br />
ng/ml<br />
transcripts are expressed in rabbit <strong>and</strong><br />
human ligament (including anterior<br />
cruciate ligament) in both sexes.<br />
Message levels for the estrogen receptor<br />
were influenced during pregnancy<br />
while message levels for the<br />
progesterone receptor were unaltered.<br />
Ligament response during pregnancy<br />
<strong>and</strong> post-partum was ligament specific<br />
when comparing the MCL <strong>and</strong> ACL.<br />
Slauterbeck et al studied<br />
ovariectomized rabbits which were<br />
given high physiologic doses <strong>of</strong><br />
estrogen for 30 days. A significant<br />
reduction in ACL load to failure was<br />
found in these rabbits vs<br />
ovariectomized rabbits without<br />
hormone administration (p=.02)<br />
suggesting that estrogen has an acute<br />
deleterious effect on ACL strength. This<br />
study indicated that the effect <strong>of</strong><br />
estrogen on ACL tissue metabolism<br />
seen by Liu et al may be responsible for<br />
the increased mechanical failure <strong>of</strong> the<br />
female ACL seen clinically.<br />
Wojtys et al attempted to link<br />
menstrual cycle phase with incidence<br />
<strong>of</strong> ACL injury. 28 women with noncontact<br />
ACL injuries were evaluated for<br />
various factors including menstrual<br />
cycle phase. The study found fewer<br />
than expected injuries in the follicular<br />
phase <strong>and</strong> greater than expected<br />
injuries in the ovulatory phase although<br />
these results were not statistically<br />
significant. Moller-Nielsen et al<br />
investigated the role <strong>of</strong> <strong>of</strong> oral<br />
contraceptives in the epidemiology <strong>of</strong><br />
traumatic soccer injuries in a<br />
prospective study <strong>of</strong> 86 female athletes.<br />
They found a statistically significant<br />
reduction in “traumatic injuries” in<br />
athletes using oral contraceptives<br />
(p=.05) however the injuries were not<br />
stratified <strong>and</strong> there is no specific data<br />
on ACL injuries. The authors<br />
attributed this difference to reduced<br />
premenstrual symptoms in OCP users.<br />
Mykelburst et al prospectively studied<br />
Norwegian h<strong>and</strong>ball players <strong>and</strong> found<br />
significantly fewer injuries during the<br />
midcycle. Of note half <strong>of</strong> the women<br />
studied by Mykelburst were taking oral<br />
contraceptive pills. These results<br />
indicated that further study was needed<br />
to determine whether cycle phase or<br />
oral contraceptive use impact ACL<br />
injury in female athletes.<br />
Our study focused on the chronic<br />
effect <strong>of</strong> hormonal milieu (ovulatory vs<br />
OCP regulated cycle) on ACL<br />
mechanics. The different hormone<br />
46 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Experimental Group<br />
Table 2: Results <strong>of</strong> ACL Mechanical Testing.<br />
levels between the control <strong>and</strong><br />
experimental groups suggest that the<br />
rats in the placebo group underwent an<br />
ovulatory cycle while the experimental<br />
group had more stable estrogen <strong>and</strong><br />
progesterone levels as is typical <strong>of</strong> cycles<br />
under oral contraceptive control. Our<br />
results show that rats having<br />
undergone 12 oestrus cycles regulated<br />
by oral contraceptive steroids vs those<br />
that have undergone 12 oestrus cycles<br />
without exogenous steroids have<br />
different ACL response to mechanical<br />
stress. Specifically the hormone treated<br />
rats had significantly increased ACL<br />
stretch prior to failure than controls.<br />
There was, however, no significant<br />
difference in peak load before failure or<br />
energy to failure. The increased stretch<br />
prior to failure may be due to a higher<br />
concentration <strong>of</strong> type 3 collagen vs type<br />
1 collagen as was found by Liu et al in<br />
their studies <strong>of</strong> acute estrogen exposure.<br />
In contrast to Slaugtherbeck et al we<br />
did not find that the ultimate load to<br />
failure was different between our two<br />
N, N/mm <strong>and</strong> mJ<br />
600<br />
500<br />
400<br />
300<br />
200<br />
100<br />
0<br />
Results <strong>of</strong> Specimen Loading<br />
p
Back Pain in Intercollegiate Rowers<br />
CAROL C. TEITZ, M.D., JOHN O’KANE, M.D., BONNIE K. LIND, M.S., AND JO A. HANNAFIN, M.D., PH.D.<br />
Stallard first reported back pain as<br />
a significant problem in rowers in<br />
1980. He noted that rowing style<br />
had changed from a straight-backed<br />
swing to a flexion <strong>and</strong> rotation <strong>of</strong> the<br />
lumbar spine at the beginning <strong>of</strong> the<br />
stroke. The frequent complaints <strong>of</strong> back<br />
pain among current intercollegiate<br />
rowers, <strong>and</strong> the lack <strong>of</strong> a large-scale<br />
intercollegiate study, prompted the<br />
authors to question whether the<br />
prevalence <strong>of</strong> back pain had increased<br />
in recent years <strong>and</strong>, if so, what factors<br />
might be contributing to back<br />
problems.<br />
METHODS<br />
Surveys were sent to 4680 former<br />
intercollegiate rowing athletes who had<br />
graduated between 1978 <strong>and</strong> 1998 from<br />
5 schools with strong rowing programs.<br />
2165 surveys were returned (46%).<br />
Subjects who had back pain before<br />
college rowing, those older than 45, <strong>and</strong><br />
those who did not indicate whether or<br />
not they had back pain in college were<br />
omitted from the analysis leaving 1632<br />
subjects.<br />
RESULTS<br />
The 1632 subjects included 936<br />
males, 694 females, <strong>and</strong> 2 subjects who<br />
did not report their sex; 71 were<br />
coxswains. The mean college height <strong>and</strong><br />
weight <strong>of</strong> rowers who are currently<br />
under age 30 is significantly greater<br />
than that <strong>of</strong> rowers older than 30<br />
(p
intercollegiate rowing has increased<br />
over the last 25 years <strong>and</strong> may reflect a<br />
complex, interrelated set <strong>of</strong> changes in<br />
the sport over time, including changes<br />
in equipment, type <strong>and</strong> intensity <strong>of</strong><br />
training, <strong>and</strong> rower physique, as well as<br />
beginning to row at a younger age.<br />
Nevertheless, ergometer training for<br />
longer than 30 minutes proved to be the<br />
most significant <strong>and</strong> consistent<br />
predictor <strong>of</strong> back pain, in every age<br />
decade <strong>and</strong> when all potential<br />
predictors were considered<br />
simultaneously.<br />
This duration <strong>of</strong> ergometer training<br />
recently has become widespread due to<br />
increased ergometer availability <strong>and</strong> to<br />
st<strong>and</strong>ardized training protocols<br />
dispensed by US Rowing. Coaches<br />
suggest that ergometer training is more<br />
difficult than rowing in the boat, <strong>and</strong><br />
that technique deteriorates during long<br />
ergometer sessions.<br />
In addition to longer ergometer<br />
training times, height is significantly<br />
associated with back pain only in our<br />
female rowers. Although we don’t know<br />
if the height increase is a function <strong>of</strong><br />
torso length or leg length, greater torso<br />
length creates increased leverage that is<br />
advantageous for rowing, but may be<br />
disadvantageous for the spine. The legs<br />
initiate the drive phase <strong>of</strong> rowing<br />
during which the trunk-thigh angle<br />
must increase. Ideally, the quadriceps<br />
extend the knee while the hamstrings<br />
simultaneously rotate the trunk.<br />
Quadriceps dominance can lead to the<br />
buttocks moving back in the boat<br />
prematurely, thus hyperflexing the<br />
lumbar spine (“shooting the tail”).<br />
Hyperflexion also occurs when<br />
hamstrings are hyperflexible or when<br />
the scapular-stabilizing muscles are not<br />
strong enough to receive the force<br />
transferred from the lower limbs. Spine<br />
hyperextension occurs when the rower<br />
increases the trunk-thigh angle by<br />
extending the spine using spinal<br />
muscles rather than by rotating the<br />
pelvis posteriorly through the hip<br />
joints. Quadriceps dominance <strong>and</strong><br />
hamstring hyperflexibility noted in<br />
female athletes may make<br />
compensating for increased leverage in<br />
the taller female rower more difficult.<br />
Koutedakis et al <strong>and</strong> Colli<strong>and</strong>er et al<br />
found a correlation between thighmuscle<br />
imbalance <strong>and</strong> back pain.<br />
Moreover, Koutedakis et al significantly<br />
reduced time loss due to back pain by<br />
instituting a hamstring-strengthening<br />
program in 22 female rowers. To protect<br />
the spine, balanced strength <strong>and</strong> good<br />
rowing technique are critical.<br />
CONCLUSION<br />
Back pain in intercollegiate rowing<br />
has increased over the last 25 years<br />
affecting 32% <strong>of</strong> 1632 intercollegiate<br />
rowers in our study. The effect on the<br />
affected athlete’s team is significant. In<br />
our study, 5.8% <strong>of</strong> rowers missed more<br />
than a month or the entire competitive<br />
season. Whether this back pain causes<br />
lifelong problems is the subject <strong>of</strong><br />
additional data analysis underway.<br />
RECOMMENDED READING<br />
Colli<strong>and</strong>er EB <strong>and</strong> Tesch PA: Bilateral<br />
eccentric <strong>and</strong> concentric torque <strong>of</strong><br />
quadriceps <strong>and</strong> hamstring muscles in<br />
females <strong>and</strong> males. Eur J Appl Physiol<br />
1989;59:227-232.<br />
Hickey GJ, Fricker PA, <strong>and</strong> McDonald<br />
WA: Injuries to elite rowers over a 10-<br />
yr period. Med Sci Sports Exerc<br />
1997;29(12): 1567-1572.<br />
Howell DW: Musculoskeletal pr<strong>of</strong>ile<br />
<strong>and</strong> incidence <strong>of</strong> musculoskeletal<br />
injuries in lightweight women rowers.<br />
Am J Sports Med 1984; 12(4): 278-282.<br />
Huston LJ <strong>and</strong> Wojtys EM:<br />
Neuromuscular Performance<br />
Characteristics in Elite Female Athletes.<br />
Am J Sports Med 1996;24(4): 427-436.<br />
Koutedakis Y, Frischknecht R <strong>and</strong><br />
Murthy M: Knee flexion to extension<br />
peak torque ratios <strong>and</strong> low-back<br />
injuries in highly active individuals. Int<br />
J Sports Med 1997; 18:290-295.<br />
Lamb DH: A kinematic comparison <strong>of</strong><br />
ergometer <strong>and</strong> on-water rowing. Am J<br />
Sports Med 1989; 17(3): 367-373.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 49
Moving Toward Knowledge Building Communities in Health<br />
Information Website Design<br />
TRACEY WAGNER, JENNIFER TURNS, KRISTEN SHUYLER, AND AARON LOUIE<br />
The Arthritis Source is a webbased<br />
information resource<br />
created to help self-motivated,<br />
geographically dispersed learners gain<br />
access to information about arthritis<br />
(www.orthop.washington.edu/<br />
arthritis). It was developed to support<br />
the needs <strong>of</strong> everyone who interacts<br />
with it: the users, the site managers, <strong>and</strong><br />
the content creators. For the past two<br />
years, the Program for Educational<br />
Transformation Through Technology<br />
(PETTT) <strong>and</strong> the UW Department <strong>of</strong><br />
Orthopaedics <strong>and</strong> Sports Medicine<br />
have used a science <strong>of</strong> learning<br />
framework to develop an analysis<br />
process <strong>and</strong> content creation system<br />
that meets the needs <strong>of</strong> both learners<br />
<strong>and</strong> teachers using the Arthritis Source.<br />
Our redesign <strong>of</strong> the Arthritis Source<br />
has been guided by both the current<br />
research on medical information<br />
websites <strong>and</strong> by our own specific<br />
concerns. A variety <strong>of</strong> current studies<br />
on the roles <strong>and</strong> effectiveness <strong>of</strong> medical<br />
websites have discussed some common<br />
shortcomings <strong>and</strong> related design<br />
decisions (e.g., Berl<strong>and</strong> et al., 2001). In<br />
our research, we have moved away from<br />
describing the community <strong>of</strong> users <strong>and</strong><br />
toward focusing on the users’ current<br />
knowledge <strong>and</strong> their goals in visiting<br />
the site. In this work we have attempted<br />
to address some <strong>of</strong> the known problems<br />
<strong>and</strong> also create a systematic solution to<br />
issues <strong>of</strong> content maintenance <strong>and</strong> site<br />
development that meets users’<br />
changing needs. We are attempting to<br />
support the subject matter experts in<br />
creating content that is appropriate for<br />
the users. Most importantly, we wanted<br />
to help patients find answers to<br />
questions concerning their conditions.<br />
We are working on a system <strong>of</strong> site<br />
architecture <strong>and</strong> content development<br />
that can be driven explicitly by both our<br />
underst<strong>and</strong>ing <strong>of</strong> users’ information<br />
needs <strong>and</strong> by users’ interactions with<br />
the site over time. As people use the site,<br />
they will collaborate with the content<br />
authors to create an information<br />
resource that serves users’ purposes <strong>and</strong><br />
will change with their needs.<br />
This redesign transforms the<br />
Arthritis Source from its original state<br />
as a static, encyclopedic object into a<br />
community <strong>of</strong> inquiry <strong>and</strong> practice in<br />
which users learn from each other’s<br />
questions <strong>and</strong> shape the growth <strong>of</strong> the<br />
knowledge base. In this effort, the<br />
designers, content authors, <strong>and</strong> users <strong>of</strong><br />
the website each learn from the others.<br />
Redesigning to support knowledge<br />
building<br />
The Arthritis Source has been a<br />
successful website since its inception<br />
about 1995. It was getting thous<strong>and</strong>s<br />
<strong>of</strong> hits per day <strong>and</strong> users were<br />
submitting unsolicited compliments<br />
through emails. The site covered<br />
Figure 1: Research <strong>and</strong> design work on the Arthritis Source has included many elements. The timeline<br />
above shows an approximate timeline <strong>of</strong> the work done on the site to date.<br />
approximately 100 topics related to<br />
arthritis <strong>and</strong> incorporated a variety <strong>of</strong><br />
media.<br />
Despite this success, we knew we<br />
wanted to make changes to the Arthritis<br />
Source – to update the information, to<br />
address the types <strong>of</strong> concerns emerging<br />
from studies <strong>of</strong> such informational<br />
websites, <strong>and</strong> to make the information<br />
more learner-centered. To address<br />
these issues, we wanted a solution that<br />
would be scalable (so we can continue<br />
to exp<strong>and</strong> the website) <strong>and</strong> enhancable<br />
(so we can make changes with<br />
reasonable levels <strong>of</strong> effort). We also<br />
recognized quickly that the information<br />
designers, content authors, <strong>and</strong> users<br />
needed to come together to collaborate<br />
on the most effective site.<br />
In making our changes, we have<br />
adopted a knowledge building<br />
community perspective. In such a<br />
community, a variety <strong>of</strong> people<br />
contribute to the accumulation <strong>of</strong><br />
knowledge, different people can<br />
contribute in different ways, the<br />
knowledge base builds up over time,<br />
<strong>and</strong> there are st<strong>and</strong>ards <strong>of</strong> quality for<br />
what belongs in the knowledge base.<br />
The members <strong>of</strong> the community learn<br />
from each other by being exposed to<br />
both the products <strong>and</strong> processes <strong>of</strong> the<br />
knowledge creation activities, which<br />
benefits them all. We are using this<br />
perspective as a way <strong>of</strong> thinking about<br />
how the users <strong>of</strong> the Arthritis Source will<br />
interact with the site, with the content<br />
authors, with the designers, <strong>and</strong> with<br />
each other.<br />
Diverse learners, but shared needs<br />
Our earliest work with the Arthritis<br />
Source consisted <strong>of</strong> various efforts to<br />
“know thy learner” so that we could<br />
create a site that was more learnercentered<br />
(Turns <strong>and</strong> Wagner, <strong>2002</strong>). We<br />
used a variety <strong>of</strong> methods to learn who<br />
was visiting the website <strong>and</strong> what they<br />
were doing during their visits. One <strong>of</strong><br />
our most comprehensive activities has<br />
been our use <strong>of</strong> an online survey in<br />
which users <strong>of</strong> the site provide us with<br />
information about themselves <strong>and</strong> their<br />
visit (Turns <strong>and</strong> Liu, 2000). Based on<br />
survey results, personal interviews, <strong>and</strong><br />
emailed comments, we know that our<br />
50 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Figure 2: Two screen captures <strong>of</strong> an article on the Arthritis Source. The article on the left has ordinary<br />
headings <strong>and</strong> body text. The article on the right shows questions in addition to the headings. These<br />
questions are used to support authors in writing the article as well as helping users.<br />
user population is widely varied, but<br />
has some common needs <strong>and</strong><br />
characteristics. The majority <strong>of</strong> the<br />
participants identified themselves as<br />
patients with arthritis (61%) or friends<br />
<strong>and</strong> relatives <strong>of</strong> an arthritis patient<br />
(8%). Patients have many different<br />
information needs <strong>and</strong> goals when they<br />
visit the site, but many patients share<br />
similar needs. The complexity <strong>of</strong> some<br />
<strong>of</strong> these needs as well as the shared<br />
nature <strong>of</strong> the various goals suggests that<br />
a potential community <strong>of</strong> learners<br />
already exists. Patients also come to the<br />
site with existing knowledge, <strong>and</strong><br />
sometimes with existing<br />
misconceptions. Many <strong>of</strong> these<br />
misconceptions are also shared (or<br />
originate from common sources),<br />
suggesting that patients may be<br />
positioned to benefit from previous<br />
visitors’ learning—the essence <strong>of</strong> a<br />
knowledge building community.<br />
From research to implementation<br />
The extent <strong>and</strong> complexity <strong>of</strong> the<br />
questions brought to the site by our<br />
learners convinced us quickly that no<br />
static system could effectively satisfy all<br />
the users. The perspective <strong>of</strong> a<br />
knowledge building community<br />
suggested that we therefore should<br />
design a system in which the learners<br />
influence the content, tuning the system<br />
to their needs over time. The current<br />
version <strong>of</strong> the Arthritis Source has been<br />
changed in several distinct ways in<br />
response to this goal. Two are briefly<br />
discussed below.<br />
Redesign element 1: Template-based<br />
content<br />
We are moving toward a version <strong>of</strong><br />
the Arthritis Source in which all content<br />
will be based on templates. The<br />
templates used in this context are a<br />
series <strong>of</strong> questions that pertain to a<br />
general class <strong>of</strong> topics <strong>and</strong> are used by<br />
the subject matter experts in the writing<br />
<strong>of</strong> articles within the topics. Templates<br />
perform several roles within the site:<br />
Templates are key to the learnercentered<br />
content – they are links<br />
between research <strong>and</strong> content.<br />
Figure 3: Two screen captures <strong>of</strong> the question-based navigation pages on the Arthritis Source. The<br />
three search options are shown on the left. If the users types a question into the top box, the search<br />
results appear as shown on the right. Returned articles can be read (<strong>and</strong> ranked), or the question can<br />
be restated or submitted for further review in the lower boxes.<br />
Template elements become<br />
navigation elements.<br />
Template-driven content has<br />
consistent structure across articles.<br />
Templates communicate to author<br />
what learners want to know.<br />
Redesign element 2: Question-based<br />
navigation<br />
The content <strong>of</strong> the site, while<br />
accessible in the usual browsing mode,<br />
is also tailored via the templates to<br />
support a question-based navigation<br />
system. This system allows learners to<br />
ask free text questions, <strong>and</strong> it responds<br />
to them with authoritative, relevant text<br />
that has been written based on a<br />
learner-centered approach. The system<br />
responds to such questions in two<br />
possible ways, each supporting a kind<br />
<strong>of</strong> community knowledge building.<br />
After a learner asks a question, the<br />
system returns several pre-answered<br />
questions within articles that may<br />
address the question. If the learner<br />
cannot find any useful information by<br />
asking or rephrasing the question, he<br />
or she is invited to submit the question<br />
to the content developers. These<br />
developers will then be able to add<br />
appropriate content to answer the<br />
question or improve the search system.<br />
The question-based search system<br />
provides several benefits to the site <strong>and</strong><br />
the users:<br />
Permits users to start at natural<br />
starting point, questions.<br />
Helps users navigate through large<br />
body <strong>of</strong> information.<br />
Educational benefits (scaffolding)<br />
when seeing others’ questions.<br />
By collecting unanswered questions,<br />
our research continues.<br />
CONCLUSION<br />
This implementation transforms<br />
the Arthritis Source from a static<br />
information source to the continually<br />
evolving product <strong>of</strong> a knowledge<br />
building community. The boundaries<br />
between the creators (the content<br />
authors <strong>and</strong> the information designers)<br />
<strong>and</strong> the consumers (the users) <strong>of</strong> the<br />
information are blurred. This<br />
implementation <strong>of</strong> the Arthritis Source<br />
provides a means by which the users,<br />
content authors, <strong>and</strong> information<br />
designers become members <strong>of</strong> a<br />
community jointly influencing the<br />
scope <strong>and</strong> organization <strong>of</strong> the<br />
knowledge source. The ongoing choice<br />
<strong>of</strong> articles <strong>and</strong> the sequence <strong>of</strong> their<br />
content is the result <strong>of</strong> a collaboration<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 51
etween arthritis patients <strong>and</strong> site<br />
designers in which the designers<br />
learned about the patients’ information<br />
needs. Users’ efforts to construct their<br />
own knowledge with this site can now<br />
be seen as a collaboration between these<br />
users, earlier users who influenced the<br />
content, <strong>and</strong> the content authors <strong>and</strong><br />
information designers.<br />
RECOMMENDED READING<br />
Berl<strong>and</strong>, G.K., Elliott, M.N., Morales,<br />
L.S., Algazy, J.I., Kravitz, R.L., Broder,<br />
M.S., Kanouse, D.E., Munoz, J.A., Puyol,<br />
J.A., Lara, M., Watkins, K.E., Yang, <strong>and</strong><br />
McGlynn, E.A. (2001). Health<br />
information on the internet:<br />
Accessibility, Quality, <strong>and</strong> Readability in<br />
Spanish <strong>and</strong> English, Journal <strong>of</strong> the<br />
American Medical Association, May 23/<br />
30: Vol 285(20), pp. 2612-2621.<br />
Turns, J. <strong>and</strong> Liu, K. (2000). Online<br />
Survey Results. Technical Report.<br />
Turns, J. <strong>and</strong> Wagner, T. (<strong>2002</strong>)<br />
Listening to the learners: A case study<br />
in health information website design.<br />
Society <strong>of</strong> Technical Communication’s<br />
49th Annual Conference (Nashville,<br />
TN, May <strong>2002</strong>).<br />
52 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Optimizing the Intrinsic Stability <strong>of</strong> the Glenoid Fossa With<br />
Non-Prosthetic Glenoid Arthroplasty<br />
EDWARD J. WELDON III, M.D., RICHARD S. BOORMAN, M.D., M.SC., KEVIN L. SMITH, M.D.,<br />
AND FREDERICK A. MATSEN III, M.D.<br />
In shoulders requiring arthroplasty,<br />
the extant glenoid may provide<br />
insufficient intrinsic stability for<br />
the humeral head - for example if the<br />
glenoid is flat or biconcave. In such<br />
cases the surgeon can restore the<br />
desired intrinsic stability using a<br />
glenoid prosthesis with a known surface<br />
geometry. Alternatively, the surgeon<br />
can modify the surface <strong>of</strong> the glenoid<br />
to a geometry that provides the desired<br />
intrinsic stability. This study explores<br />
the feasibility, reliability <strong>and</strong><br />
predictability with which glenoid<br />
intrinsic stability can be restored<br />
through spherical reaming <strong>of</strong> the<br />
glenoid bone around the glenoid<br />
centerline. It tests the hypothesis that<br />
the intrinsic stability <strong>of</strong> reamed<br />
glenoids can match that <strong>of</strong> clinically<br />
used polyethylene glenoid components.<br />
Figure 1: Balance stability angles. a) Consider a glenoid that has a centerline “C” perpendicular to<br />
the surface at the center <strong>of</strong> the glenoid <strong>and</strong> that has a radius <strong>of</strong> curvature “R” as well as a width “W”<br />
in a specified direction from center to edge. b) Consider an unattached humeral head component<br />
articulating with this glenoid for which the sum <strong>of</strong> all forces acting on it is F, the net humeral joint<br />
reaction force. The vector F makes an angle with the centerline, C, <strong>of</strong> Ø. If the humeral head is free<br />
to move under the influence <strong>of</strong> gravity, F becomes the gravitational force vector <strong>and</strong> is always vertical.<br />
By tipping the glenoid, Ø can be progressively increased. c) As Ø is increased, it reaches a value at<br />
which the humeral head dislocates over the edge <strong>of</strong> the glenoid. This value for Ø is known as the<br />
balance stability angle, or BSA. If R <strong>and</strong> W are known, Ø can be predicted from sine Ø = W/R, or Ø =<br />
arc sine W/R.<br />
Figure 2: The glenoidogram. a) The glenoidogram in a given direction is the path traced by the humeral<br />
head as it travels across the glenoid surface in the direction <strong>of</strong> interest. b) The width (W) <strong>and</strong> depth (D)<br />
<strong>of</strong> the effective concavity can be seen on the glenoidogram. The maximal slope <strong>of</strong> the glenoidogram<br />
(S) is the tangent <strong>of</strong> the balance stability angle. [Matsen, 1994 #7][PEMS, R <strong>and</strong> M chapter on stability].<br />
METHODS<br />
The intrinsic stability provided by<br />
the glenoid in a given direction can be<br />
characterized by the maximal angle the<br />
humeral joint reaction force can make<br />
with the glenoid centerline before the<br />
humeral head dislocates; this quantity<br />
is defined as the balance stability angle<br />
(BSA) in the specified direction (Figure<br />
1). The BSA can be calculated by<br />
analysis <strong>of</strong> the shape <strong>of</strong> the glenoid<br />
surface (Figure 2). The BSA can also be<br />
measured directly by placing an<br />
unconstrained humeral head loaded<br />
only by gravity within the glenoid<br />
oriented with the centerline vertical <strong>and</strong><br />
then tipping the glenoid until the<br />
humeral head dislocates (Figure 1). In<br />
this study, the balance stability angles<br />
were both calculated <strong>and</strong> measured in<br />
8 different directions for 3 unused<br />
polyethylene glenoid components <strong>and</strong><br />
11 cadaveric glenoids in 4 different<br />
states: 1) native without capsule or<br />
rotator cuff, 2) denuded <strong>of</strong> cartilage <strong>and</strong><br />
labrum, 3) after reaming the glenoid<br />
surface around the glenoid centerline<br />
using a spherical reamer with a radius<br />
<strong>of</strong> 25.0 millimeters, <strong>and</strong> 4) after<br />
reaming around the glenoid centerline<br />
using a spherical reamer with a radius<br />
<strong>of</strong> 22.5 millimeters (Figure 3). We also<br />
attempted to predict the BSAs<br />
achievable with reaming to each <strong>of</strong> the<br />
two different radii from measurement<br />
<strong>of</strong> the width <strong>of</strong> the glenoid before it was<br />
reamed.<br />
RESULTS<br />
Denuding the glenoids <strong>of</strong> their<br />
articular cartilage reduced the intrinsic<br />
stability, especially in the posterior<br />
direction (Figure 4 <strong>and</strong> Table 1).<br />
Reaming the glenoid restored the<br />
intrinsic stability back to values<br />
comparable to those <strong>of</strong> the normal<br />
glenoid. For example, the average<br />
calculated BSA in the posterior<br />
direction for all eleven glenoids was:<br />
native = 24°± 9°, denuded = 14°± 6°,<br />
reamed to radius 25.0 millimeter = 25°<br />
± 5°, reamed to radius 22.5 millimeter<br />
= 33° ± 6°. The BSAs for the<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 53
Figure 3: The different glenoid states. (a) The native glenoid in which the capsular tissues have been dissected from the labrum. (b) The denuded glenoid in<br />
which the articular cartilage <strong>and</strong> glenoid labrum have been curetted from the bony surface <strong>of</strong> the glenoid. (c) The glenoid reamed to 25.0 millimeters in which<br />
the glenoid has been spherically reamed to a radius <strong>of</strong> curvature <strong>of</strong> 25.0 millimeters around the glenoid centerline. (d) The glenoid reamed to 22.5 millimeters<br />
in which the glenoid has been spherically reamed to a radius <strong>of</strong> curvature <strong>of</strong> 22.5 millimeters around the glenoid centerline.<br />
The proportions <strong>of</strong> the concavities <strong>of</strong> these glenoid cross-sections have been drawn based on the average depth (D) <strong>and</strong> width (W) from the 11 glenoids in each<br />
<strong>of</strong> the four states in the anterior to posterior (90º to 270º) direction. The representative photos below show glenoid #5 in each <strong>of</strong> its 4 states. a) native. b)<br />
denuded. c) reamed 25.0. d) reamed 22.5.<br />
o<br />
10<br />
o<br />
315<br />
8<br />
40<br />
30<br />
o<br />
45 2<br />
20<br />
10<br />
o<br />
270 7<br />
0<br />
o<br />
90 3<br />
6o<br />
225<br />
5 o<br />
180<br />
Reamed 22.5<br />
Reamed 25.0<br />
Native<br />
Denuded<br />
4<br />
135<br />
o<br />
Figure 4: Intrinsic stability <strong>of</strong> the four different glenoid states, native, denuded, reamed to 25 mm, <strong>and</strong> reamed to 22.5 mm. The BSAs are shown in degrees.<br />
Note the particularly dramatic loss in posterior <strong>and</strong> posterior-inferior intrinsic stability with denuding the native glenoid <strong>of</strong> articular cartilage. Note also the<br />
restoration <strong>of</strong> the BSAs with spherical reaming to 25 <strong>and</strong> to 22.5 mm.<br />
54 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
o<br />
01<br />
315<br />
8<br />
o<br />
40<br />
30<br />
45<br />
2<br />
o<br />
20<br />
10<br />
o<br />
7<br />
270<br />
0<br />
/<br />
90<br />
3<br />
o<br />
o<br />
6<br />
225<br />
Reamed 22.5<br />
Global 44<br />
Reamed 25.0<br />
135 4<br />
o<br />
o<br />
180 5<br />
Figure 5: Comparative intrinsic stability <strong>of</strong> the three unused polyethylene glenoid components with a radius <strong>of</strong> curvature <strong>of</strong> 25 mm to the average intrinsic<br />
stability <strong>of</strong> the 11 cadaveric glenoid’s in their reamed 25.0 <strong>and</strong> reamed 22.5 states. The BSAs are shown in degrees.<br />
Calculated<br />
BSA<br />
(degrees)<br />
60<br />
40<br />
20<br />
Y = .89X + 2.97<br />
r2 = .76<br />
r = .87<br />
0<br />
0 20 40 60<br />
Measured BSA (degrees)<br />
Figure 6: Scatter plot comparing the calculated <strong>and</strong> measured Balance Stability Angles <strong>of</strong> all 11 glenoids<br />
in all 4 states in the anterior <strong>and</strong> posterior directions (90º to 270º).<br />
ranged from .75 to .94. All correlations<br />
were significant (p
Predicted<br />
50<br />
45<br />
40<br />
35<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
0 2 0 4 0 6 0<br />
Calculated<br />
Reamed 25.0<br />
Reamed 22.5<br />
Figure 7: Plot <strong>of</strong> calculated vs predicted BSA in degrees in the anterior <strong>and</strong> posterior directions.<br />
Direction<br />
(degrees)<br />
0<br />
45<br />
90<br />
135<br />
180<br />
225<br />
270<br />
315<br />
Native<br />
31.3<br />
24.5<br />
21.9<br />
28.4<br />
32.1<br />
28.8<br />
23.9<br />
25.4<br />
Average BSAs (degrees)<br />
Ream Ream Global<br />
Denuded<br />
*<br />
25.0<br />
** 22.5<br />
+<br />
44<br />
++<br />
29.1 34.8 40.6 36.3<br />
25.8<br />
17.9<br />
23.0<br />
23.3<br />
18.5<br />
14.1<br />
20.2<br />
30.4<br />
27.2<br />
32.6<br />
32.2<br />
28.4<br />
24.8<br />
31.6<br />
36.5<br />
33.2<br />
38.0<br />
37.3<br />
34.8<br />
32.5<br />
35.4<br />
31.9<br />
25.8<br />
31.9<br />
36.2<br />
31.2<br />
25.3<br />
31.2<br />
direction <strong>of</strong> humeral head<br />
displacement in glenohumeral arthritis.<br />
CLINICAL RELEVANCE<br />
Non-prosthetic glenoid<br />
arthroplasty through spherical reaming<br />
can achieve surface geometry <strong>and</strong><br />
intrinsic stability similar to that <strong>of</strong><br />
normal glenoids <strong>and</strong> that provided by<br />
a polyethylene glenoid.<br />
RECOMMENDED READING<br />
Levine, W. N., Djurasovic, M., Glasson,<br />
J. M., Pollock, R. G., Flatow, E. L., <strong>and</strong><br />
Bigliani, L. U. Hemiarthroplasty for<br />
glenohumeral osteoarthritis: results<br />
correlated to degree <strong>of</strong> glenoid wear. J<br />
Shoulder Elbow Surg 6 (5): 449-54,<br />
1997.<br />
Matsen, F. A., Lippitt, S. B., Sidles, J. A.,<br />
<strong>and</strong> Harryman, D. T. “Practical<br />
Evaluation <strong>and</strong> Management <strong>of</strong> the<br />
Shoulder.” W.B. Saunders Company,<br />
Philadelphia, 1994.<br />
* -significantly less than Native (p
Department <strong>of</strong> Orthopaedics <strong>and</strong> Sports Medicine Faculty<br />
Frederick A. Matsen III, M.D.<br />
Pr<strong>of</strong>essor <strong>and</strong> Chair<br />
Christopher H. Allan, M.D.<br />
Assistant Pr<strong>of</strong>essor<br />
David P. Barei, M.D.<br />
Assistant Pr<strong>of</strong>essor<br />
Carlo Bellabarba, M.D.<br />
Assistant Pr<strong>of</strong>essor<br />
Stephen K. Benirschke, M.D.<br />
Pr<strong>of</strong>essor<br />
James D. Bruckner, M.D.<br />
Associate Pr<strong>of</strong>essor<br />
Howard A. Chansky, M.D.<br />
Associate Pr<strong>of</strong>essor<br />
Jens R. Chapman, M.D.<br />
Pr<strong>of</strong>essor<br />
John M. Clark, M.D., Ph.D.<br />
Associate Pr<strong>of</strong>essor<br />
Ernest U. Conrad III, M.D.<br />
Pr<strong>of</strong>essor<br />
Mohammad Diab, M.D.<br />
Assistant Pr<strong>of</strong>essor<br />
David R. Eyre, Ph.D.<br />
Pr<strong>of</strong>essor<br />
John Green, M.D.<br />
Associate Pr<strong>of</strong>essor<br />
Theodore K. Greenlee, Jr., M.D.<br />
Associate Pr<strong>of</strong>essor<br />
Ted Gross, Ph.D.<br />
Associate Pr<strong>of</strong>essor<br />
Douglas P. Hanel, M.D.<br />
Pr<strong>of</strong>essor<br />
Sigvard T. Hansen, Jr., M.D.<br />
Pr<strong>of</strong>essor<br />
M. Bradford Henley, M.D.<br />
Associate Pr<strong>of</strong>essor<br />
Todd Jarosz, M.D.<br />
Assistant Pr<strong>of</strong>essor<br />
Nancy J. Kadel, M.D.<br />
Assistant Pr<strong>of</strong>essor<br />
Roger V. Larson, M.D.<br />
Associate Pr<strong>of</strong>essor<br />
Seth S. Leopold, M.D.<br />
Associate Pr<strong>of</strong>essor<br />
William J. Mills, M.D.<br />
Assistant Pr<strong>of</strong>essor<br />
Sohail K. Mirza, M.D.<br />
Assistant Pr<strong>of</strong>essor<br />
Vincent S. Mosca, M.D.<br />
Associate Pr<strong>of</strong>essor<br />
Sean E. Nork, M.D.<br />
Assistant Pr<strong>of</strong>essor<br />
John O’Kane, M.D.<br />
Assistant Pr<strong>of</strong>essor<br />
Milton L. Routt, Jr., M.D.<br />
Pr<strong>of</strong>essor<br />
Bruce J. Sangeorzan, M.D.<br />
Pr<strong>of</strong>essor<br />
Gregory A. Schmale, M.D.<br />
Assistant Pr<strong>of</strong>essor<br />
John A. Sidles, Ph.D.<br />
Pr<strong>of</strong>essor<br />
Peter T. Simonian, M.D.<br />
Associate Pr<strong>of</strong>essor<br />
Douglas G. Smith, M.D.<br />
Associate Pr<strong>of</strong>essor<br />
Kevin L. Smith, M.D.<br />
Associate Pr<strong>of</strong>essor<br />
Kit M. Song, M.D.<br />
Associate Pr<strong>of</strong>essor<br />
Sundar Srinivasan, Ph.D.<br />
Research Assistant Pr<strong>of</strong>essor<br />
Lynn T. Staheli, M.D.<br />
Pr<strong>of</strong>essor Emeritus<br />
Carol C. Teitz, M.D.<br />
Pr<strong>of</strong>essor<br />
Allan F. Tencer, Ph.D.<br />
Pr<strong>of</strong>essor<br />
Thomas E. Trumble, M.D.<br />
Pr<strong>of</strong>essor<br />
Jiann-Jiu Wu, Ph.D.<br />
Research Associate Pr<strong>of</strong>essor<br />
Liu Yang, Ph.D.<br />
Research Assistant Pr<strong>of</strong>essor<br />
Adjunct Faculty<br />
Basia R. Belza, R.N., Ph.D.<br />
Associate Pr<strong>of</strong>essor, Physiological<br />
Nursing<br />
Jack W. Berryman, Ph.D.<br />
Pr<strong>of</strong>essor, Medical History & Ethics<br />
Charles H. Chesnut, M.D.<br />
Pr<strong>of</strong>essor, Nuclear Medicine<br />
R<strong>and</strong>al P. Ching, Ph.D.<br />
Assistant Pr<strong>of</strong>essor, Mechanical<br />
Engineering<br />
Eva M. Escobedo, M.D.<br />
Assistant Pr<strong>of</strong>essor, Radiology<br />
Gregory C. Gardner, M.D.<br />
Associate Pr<strong>of</strong>essor, Rheumatology<br />
Thurman Gillespy, M.D.<br />
Associate Pr<strong>of</strong>essor, Radiology<br />
Daniel O. Graney, Ph.D.<br />
Associate Pr<strong>of</strong>essor, Biological<br />
Structure<br />
John C. Hunter, M.D.<br />
Associate Pr<strong>of</strong>essor, Radiology<br />
Frederick A. Mann, M.D.<br />
Pr<strong>of</strong>essor, Radiology<br />
David W. Newell, M.D.<br />
Pr<strong>of</strong>essor, Neuroscience<br />
Susan M. Ott, M.D.<br />
Associate Pr<strong>of</strong>essor, Division <strong>of</strong><br />
Metabolism<br />
Wendy Raskind, M.D., Ph.D.<br />
Associate Pr<strong>of</strong>essor, General Internal<br />
Medicine<br />
Michael L. Richardson, M.D.<br />
Pr<strong>of</strong>essor, Radiology<br />
Christopher I. Shaffrey, M.D.<br />
Associate Pr<strong>of</strong>essor, Neuroscience<br />
Robert B. Schoene, M.D.<br />
Pr<strong>of</strong>essor, Medicine<br />
Peter A. Simkin, M.D.<br />
Pr<strong>of</strong>essor, Medicine<br />
Tony J. Wilson, M.D.<br />
Pr<strong>of</strong>essor, Radiology<br />
<strong>Joint</strong> Faculty<br />
Mark A. Harrast, M.D.<br />
Assistant Pr<strong>of</strong>essor, Rehab Medicine<br />
John E. Olerud, M.D.<br />
Pr<strong>of</strong>essor, Division <strong>of</strong> Dermatology<br />
Nathan J. Smith, M.D.<br />
Pr<strong>of</strong>essor Emeritus, Pediatrics<br />
Michael D. Strong, Ph.D.<br />
Research Pr<strong>of</strong>essor, Surgery<br />
Nicholas B. Vedder, M.D.<br />
Associate Pr<strong>of</strong>essor, Plastic Surgery<br />
Clinical Faculty<br />
Sarah E. Jackins, R.P.T.<br />
Assistant Pr<strong>of</strong>essor, Rehab Medicine<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 57
<strong>University</strong> <strong>of</strong> <strong>Washington</strong><br />
<strong>University</strong> <strong>of</strong> <strong>Washington</strong> School <strong>of</strong> Medicine<br />
Department <strong>of</strong> Orthopaedics <strong>and</strong> Sports Medicine<br />
1959 N.E. Pacific Street<br />
Box 356500<br />
Seattle, <strong>Washington</strong> 98195-6500<br />
Phone: (206) 543-3690<br />
Fax: (206) 685-3139<br />
Affiliated Institutions<br />
Children’s Hospital <strong>and</strong><br />
Regional Medical Center<br />
4800 S<strong>and</strong> Point Way NE<br />
Seattle, WA 98105<br />
(206) 526-2000<br />
Harborview Medical Center<br />
325 Ninth Avenue<br />
Seattle, WA 98104<br />
(206) 731-3462<br />
<strong>University</strong> <strong>of</strong> <strong>Washington</strong><br />
Medical Center<br />
<strong>Bone</strong> <strong>and</strong> <strong>Joint</strong> Center<br />
4245 Roosevelt Way NE<br />
Seattle, WA 98105<br />
(206) 598-4288<br />
VA Puget Sound Health<br />
Care System<br />
1660 South Columbian Way<br />
Seattle, WA 98108<br />
(206) 764-2215<br />
58 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Graduating Residents<br />
Class <strong>of</strong> <strong>2002</strong><br />
Timothy DuMontier, M.D.: Tim will<br />
begin a one-year foot <strong>and</strong> ankle<br />
fellowship with Art Manoli in<br />
Michigan. Thereafter he will return to<br />
Montana to start a general orthopaedic<br />
practice.<br />
William Sims, M.D.: Bill will begin a<br />
one-year fellowship with Dr. Champ<br />
Baker at the Hughston Clinic in<br />
Columbus, Georgia.<br />
Timothy Rapp, M.D.: Following his<br />
residency he will be doing an oncology<br />
fellowship at the <strong>University</strong> <strong>of</strong><br />
<strong>Washington</strong> Medical Center.<br />
Scott Hacker, M.D.: Scott will begin a<br />
one-year sports medicine fellowship in<br />
Vail, Colorado. Following his<br />
fellowship he hopes to return to the<br />
west coast.<br />
Carla Smith, M.D.: Carla will begin an<br />
AO trauma fellowship at the <strong>University</strong><br />
<strong>of</strong> Zurich, followed by volunteering in<br />
general orthopaedics in Bhutan <strong>and</strong><br />
pediatric orthopaedics in Nepal. She<br />
will return to Harborview to do a<br />
trauma fellowship.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 59
Incoming Residents<br />
Heidi Ambrose: Heidi attended the<br />
<strong>University</strong> <strong>of</strong> San Diego where she<br />
received a BA in Chemistry. She<br />
received her medical degree from the<br />
<strong>University</strong> <strong>of</strong> <strong>Washington</strong>. She is<br />
completing her surgical internship at<br />
the <strong>University</strong> <strong>of</strong> <strong>Washington</strong>. Her<br />
interests outside <strong>of</strong> medicine include<br />
basketball, snow skiing, as well as piano<br />
<strong>and</strong> ceramics.<br />
Eric Klineberg: Eric received his BA in<br />
Biology <strong>and</strong> Studio Art from Rice<br />
<strong>University</strong>. This was followed by<br />
obtaining a Master <strong>of</strong> Science in<br />
zoology – neural science from the<br />
<strong>University</strong> <strong>of</strong> Maryl<strong>and</strong>. Eric received<br />
his medical degree from the <strong>University</strong><br />
<strong>of</strong> Maryl<strong>and</strong>. He is currently<br />
completing his internship at the<br />
<strong>University</strong> <strong>of</strong> <strong>Washington</strong>. His interests<br />
include basketball, football <strong>and</strong> golf.<br />
Melvin Wahl: Mel received his BS in<br />
Human Biology from Eastern<br />
<strong>Washington</strong> <strong>University</strong>. He earned his<br />
medical degree from the <strong>University</strong> <strong>of</strong><br />
<strong>Washington</strong>. He is currently<br />
completing his internship at the<br />
<strong>University</strong> <strong>of</strong> <strong>Washington</strong>. Outside<br />
interests include sports such as<br />
basketball, wrestling, fishing <strong>and</strong> golf.<br />
Stacey Donion: Stacey attended the<br />
<strong>University</strong> <strong>of</strong> <strong>Washington</strong> where she<br />
received a BS in Psychology <strong>and</strong><br />
Physical Therapy. She also received her<br />
M.D. from the <strong>University</strong> <strong>of</strong><br />
<strong>Washington</strong>. She is finishing her<br />
surgical internship at the <strong>University</strong> <strong>of</strong><br />
<strong>Washington</strong>. Personal interests include<br />
swimming, soccer <strong>and</strong> skiing.<br />
William Montgomery: Bill obtained his<br />
BS degree in Early Childhood<br />
Education from the <strong>University</strong> <strong>of</strong><br />
Vermont <strong>and</strong> a Masters degree in Public<br />
Health at the <strong>University</strong> <strong>of</strong> Hawaii. He<br />
also received his M.D. from the<br />
<strong>University</strong> <strong>of</strong> Hawaii. He is currently<br />
completing his internship at the<br />
<strong>University</strong> <strong>of</strong> <strong>Washington</strong>. Bill enjoys<br />
spending time with his wife <strong>and</strong><br />
children, hiking, swimming.<br />
Burt Yaszay: Burt received his BS in<br />
Biochemistry <strong>and</strong> Cell Biology from<br />
UC-San Diego. He earned his M.D.<br />
from Stanford. He is currently<br />
completing his internship at the<br />
<strong>University</strong> <strong>of</strong> <strong>Washington</strong>. His personal<br />
interests include working out at the<br />
gym, biking <strong>and</strong> travelling.<br />
60 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
<strong>2002</strong> Department <strong>of</strong> Orthopaedics<br />
New Faculty<br />
John Green, M.D. Todd Jarosz, M.D. Seth Leopold, M.D.<br />
Dr. Green received his<br />
undergraduate degree in Biopsychology<br />
as well as his<br />
medical degree from the <strong>University</strong> <strong>of</strong><br />
Cincinnati. His internship <strong>and</strong><br />
residency training in orthopaedic<br />
surgery were completed at Michigan<br />
State <strong>University</strong>/McLaren Regional<br />
Medical Center. Dr. Green then went<br />
on to complete his sports medicine<br />
fellowship training at the Minneapolis<br />
Sports Medicine Center. In 1997 he was<br />
recruited to begin a sports medicine<br />
program at LSU Health Sciences Center<br />
in Shreveport, Louisiana. Dr. Green is<br />
the new director <strong>of</strong> the <strong>University</strong> <strong>of</strong><br />
<strong>Washington</strong> Sports Medicine Clinic in<br />
the Hec Edmundson Pavilion where he<br />
specializes in the surgical treatment <strong>of</strong><br />
sports injuries.<br />
Dr. Jarosz completed his<br />
undergraduate education at<br />
Albright College in Reading,<br />
Pennsylvania. He, then, received his<br />
medical degree from the <strong>University</strong> <strong>of</strong><br />
Medicine & Dentistry Robert Wood<br />
Johnson Medical School@Camden. He<br />
completed a General Surgical<br />
Internship <strong>and</strong> Residency in<br />
Orthopaedic Surgery at the <strong>University</strong><br />
<strong>of</strong> Virginia. He also completed three<br />
additional years <strong>of</strong> advanced training<br />
by completing a two-year<br />
Sportsmedicine fellowship in Orl<strong>and</strong>o,<br />
Florida, <strong>and</strong> a fellowship in Spinal/<br />
Reconstructive Surgery at the<br />
<strong>University</strong> <strong>of</strong> Maryl<strong>and</strong>. He has a<br />
special interest in sports-related spinal<br />
injury, complex spinal reconstructive<br />
surgery, <strong>and</strong> shoulder <strong>and</strong> knee<br />
arthroscopy. He is involved with<br />
patient care at the <strong>University</strong> <strong>of</strong><br />
<strong>Washington</strong> Hospital, Harborview<br />
Medical Center, <strong>and</strong> the Eastside Clinic.<br />
Dr. Leopold received his medical<br />
degree with honors in research<br />
from Cornell <strong>University</strong> in<br />
1993. Subsequently, he completed an<br />
orthopaedic surgery residency at the<br />
<strong>University</strong> <strong>of</strong> Chicago, <strong>and</strong> pursued<br />
subspecialty training in joint<br />
replacement at Rush-Presbyterian-St.<br />
Luke’s Medical Center, an<br />
internationally-known referral hospital<br />
for complex joint reconstruction. Dr.<br />
Leopold comes to UW after serving<br />
three years in the US Army Medical<br />
Corps, where he taught <strong>and</strong> performed<br />
joint replacement surgery, <strong>and</strong> pursued<br />
research interests related to both basic<br />
science <strong>and</strong> clinical aspects <strong>of</strong> arthritis<br />
surgery. His practice serves patients<br />
with arthritis, especially <strong>of</strong> the hips <strong>and</strong><br />
knees, as well as individuals suffering<br />
with persistently painful or failed joint<br />
replacements. In addition, Dr. Leopold<br />
is experienced at a variety <strong>of</strong> minimallyinvasive<br />
joint replacement techniques,<br />
which can significantly shorten the<br />
recovery period following surgery in<br />
properly-selected patients. Dr. Leopold<br />
sees patients on the Eastside <strong>and</strong> at<br />
UWMC-Roosevelt.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 61
RESEARCH GRANTS<br />
DEPARTMENT OF ORTHOPAEDICS AND SPORTS MEDICINE<br />
National Institutes <strong>of</strong> Health (NIH)<br />
Augmentation <strong>of</strong> Peak <strong>Bone</strong> Mass<br />
Ted S. Gross, Ph.D.<br />
Collagens <strong>of</strong> Cartilage <strong>and</strong> the Intervertebral Disc<br />
David R. Eyre, Ph.D.<br />
Disuse Induced Osteocyte Hypoxia<br />
Ted S. Gross, Ph.D.<br />
Imaging <strong>of</strong> Molecules by Oscillator-Coupled Resonance<br />
John A. Sidles, Ph.D.<br />
Outcomes Following Limb Reconstruction Vs Amputation<br />
Douglas G. Smith, M.D.<br />
Pathology <strong>of</strong> Inborn Skeletal Diseases<br />
David R. Eyre, Ph.D.<br />
Skeletal Dysplasias<br />
David R. Eyre, Ph.D.<br />
TLS <strong>and</strong> TLS Fusion Proteins in Leukemia<br />
Liu Yang, Ph.D.<br />
Veterans Affairs Medical Center Review Grants<br />
Effect <strong>of</strong> Motor Imbalance on Bony Deformity <strong>and</strong> Plantar Pressure<br />
Bruce J. Sangeorzan, M.D.<br />
Ewing’s Sarcoma Fusion Proteins <strong>and</strong> mRNA Splicing Factors<br />
Howard A. Chansky, M.D.<br />
Rehabilitation Research <strong>and</strong> Development Center <strong>of</strong> Excellence for Limb Loss<br />
Prevention <strong>and</strong> Prosthetic Engineering<br />
Bruce J. Sangeorzan, M.D.<br />
Centers for Disease Control<br />
Age-Related Cervical Spine Mechanics <strong>and</strong> Injury Tolerance<br />
R<strong>and</strong>al P. Ching, Ph.D.<br />
Development <strong>of</strong> a Device to Reduce Cervical Whiplash Potential in Rear-End<br />
Car Accidents<br />
Allan F. Tencer, Ph.D.<br />
62 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
RESEARCH GRANTS<br />
DEPARTMENT OF ORTHOPAEDICS AND SPORTS MEDICINE<br />
Orthopaedic Research <strong>and</strong> Education Foundation (OREF)<br />
Overcoming Nerve Defect by Growth Factor Stimulated Regeneration Along<br />
Intact Nerves<br />
Thomas E. Trumble, M.D.<br />
Ben Dubois, M.D.<br />
Reproductive Hormone Effects on ACL Strength<br />
Emma Woodhouse, M.D.<br />
Peter T. Simonian, M.D.<br />
Toward Clinical Application <strong>of</strong> the Intact Nerve Bridge Technique: Longer Term<br />
Study in a Rabbit Model<br />
Thomas E. Trumble, M.D.<br />
Wren V. McCallister, M.D.<br />
American Federation for Aging Research<br />
Rest-Inserted Loading: Examination <strong>of</strong> a Novel Osteogenic Stimulus For the<br />
Aged Skeleton<br />
Sundar Srinivasan, Ph.D.<br />
Alberta Heritage Foundation for Medical Research<br />
Shoulder Laxity<br />
Richard S. Boorman, M.D.<br />
American Society for Surgery <strong>of</strong> the H<strong>and</strong><br />
Bridging Versus Non-Bridging External Fixation <strong>of</strong> Distal Radius Fractures: a<br />
Measure <strong>of</strong> Structural Rigidity in an Unstable Fracture Model<br />
Thomas E. Trumble, M.D.<br />
Prospective R<strong>and</strong>omized Clinical Trial <strong>of</strong> H<strong>and</strong> Therapy Following Carpal<br />
Tunnel Surgery<br />
Thomas E. Trumble, M.D.<br />
Defense Advanced Research Projects Agency<br />
The Accelerated Development <strong>of</strong> MRFM<br />
John A. Sidles, Ph.D.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 63
RESEARCH GRANTS<br />
DEPARTMENT OF ORTHOPAEDICS AND SPORTS MEDICINE<br />
DePuy Orthopaedics, Inc.<br />
THA Range Of Motion Study<br />
R<strong>and</strong>al P. Ching, Ph.D.<br />
Thermal Effects <strong>of</strong> Two Different Glenoid Fixation Techniques<br />
Sean R. Churchill, M.D.<br />
Frederick A. Matsen III, M.D.<br />
Ethicon<br />
Role <strong>of</strong> <strong>Bone</strong> in Cartilage Transplantation<br />
Peter T. Simonian, M.D.<br />
Genetics Institute<br />
A Feasibility <strong>and</strong> Safety Study <strong>of</strong> rhBMP-2/ACS <strong>and</strong> Allograft Compared to<br />
Autogenous <strong>Bone</strong> Graft for Patients with Severe Tibial Shaft Fractures<br />
Sohail K. Mirza, M.D.<br />
Leukemia Research Foundation<br />
Disruption <strong>of</strong> RNA Splicing by TLS/ERG Leukemia Fusion Protein<br />
Liu Yang, Ph.D.<br />
National Childhood Cancer Foundation<br />
Childrens Cancer Group<br />
Ernest U. Conrad III, M.D.<br />
National Highway Traffic Safety Administration<br />
Neck Mechanics <strong>and</strong> Injury Tolerance as a Function <strong>of</strong> Developmental Age<br />
R<strong>and</strong>al P. Ching, Ph.D.<br />
National Leukemia Research Association<br />
Canine Leukocyte Adhesion Deficiency Studies<br />
Liu Yang, Ph.D.<br />
Novartis Pharmaceuticals Corporation<br />
Cartilage Collagen Study<br />
David R. Eyre, Ph.D.<br />
64 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
RESEARCH GRANTS<br />
DEPARTMENT OF ORTHOPAEDICS AND SPORTS MEDICINE<br />
Orthopaedic Trauma Association<br />
Immediate vs. Delayed Closure <strong>of</strong> Type II <strong>and</strong> IIIA Open Tibia Fractures<br />
M. Bradford Henley, M.D.<br />
Ostex International, Inc.<br />
Molecular Markers <strong>of</strong> Connective Tissue Degradation<br />
David R. Eyre, Ph.D.<br />
Pfizer, Inc.<br />
Guinea Pig Osteoarthritis<br />
David R. Eyre, Ph.D.<br />
Spinal Dynamics Corp.<br />
BRD Functional Disc Space Prosthesis Development Project<br />
R<strong>and</strong>al P. Ching, Ph.D.<br />
Functional Intervertebral Disc Space Prosthesis Development Project<br />
R<strong>and</strong>al P. Ching, Ph.D.<br />
The Boeing Company<br />
R<strong>and</strong>omized Clinical Trial <strong>of</strong> Open versus Endoscopic Carpal Tunnel Release<br />
<strong>and</strong> H<strong>and</strong> Therapy Comparing Patient Satisfaction: Functional Outcome<br />
<strong>and</strong> Cost Effectiveness<br />
Thomas E. Trumble, M.D.<br />
The Physical Medicine Research Foundation<br />
Development <strong>of</strong> a Device to Reduce Whiplash Motion <strong>of</strong> the Cervical Spine<br />
Allan F. Tencer, Ph.D.<br />
United States Air Force Research Laboratory<br />
Pilot Study: Human Tensile Neck Injury Tolerance<br />
R<strong>and</strong>al P. Ching, Ph.D.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 65
RESEARCH GRANTS<br />
DEPARTMENT OF ORTHOPAEDICS AND SPORTS MEDICINE<br />
Whitaker Foundation<br />
Examining Processes Underlying the Dramatic Osteogenic Response Elicited by<br />
Rest-Inserted Loading<br />
Sundar Srinivasan, Ph.D.<br />
Wyeth-Ayerst Clinical Research<br />
Safety <strong>and</strong> Efficacy <strong>of</strong> Two Intravenous Dosages <strong>of</strong> GAR-936 for Complicated<br />
Skin Infections: A Prospective R<strong>and</strong>omized Trial<br />
William J. Mills, M.D.<br />
Zymogenetics<br />
An Analysis <strong>of</strong> Collagen Synthesized by Zfgf5 Treated Chondrocytes<br />
Russell J. Fern<strong>and</strong>es, Ph.D.<br />
66 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Contributors to Departmental Research <strong>and</strong> Education<br />
APRIL 2001 THROUGH MARCH <strong>2002</strong><br />
We express our appreciation to all who have contributed to the work <strong>of</strong> the Department <strong>of</strong> Orthopaedics <strong>and</strong> Sports Medicine<br />
over the past year. Your assistance makes possible special research activities, educational programs, <strong>and</strong> other projects that<br />
we could not <strong>of</strong>fer without this extra support from our alumni, faculty, <strong>and</strong> friends in the community. We owe a special<br />
thanks to the <strong>University</strong> <strong>of</strong> <strong>Washington</strong> Resident Alumni who have made significant contributions to help further the education<br />
<strong>of</strong> our current residents. We have tried to include in this list all who contributed; if anyone was overlooked, please be sure to<br />
let us know!<br />
Friends <strong>of</strong> Orthopaedics<br />
Aircast<br />
Carel Ackermann<br />
Christopher Allan<br />
Frank Alvine<br />
Debora Amara<br />
Mary Jane Anderson<br />
Craig Arntz<br />
Avanta Orthopaedics<br />
Aventis Pharmaceuticals<br />
Allan Bach<br />
Samuel Baker<br />
Ballard Orthopaedic & Fracture<br />
Clinic<br />
William Barrett<br />
Thomas Barthel<br />
Timothy Beals<br />
Carlo Bellabarba<br />
Steve Benirschke<br />
Gary Bergman<br />
American Society <strong>of</strong> Biomechanics<br />
Biomet<br />
Audrey Bixby<br />
Anne Br<strong>and</strong>on<br />
Tim Br<strong>and</strong>on<br />
Elton Brown<br />
James Bruckner<br />
Michael <strong>and</strong> Susan Cero<br />
Howard Chansky<br />
Jens Chapman<br />
Thomas Chi<br />
Gary Clancey<br />
John Clark<br />
Margaret Clark<br />
Todd Clarke<br />
Joseph C. Clifford<br />
Bill <strong>and</strong> Jane Conaway<br />
Ernest Conrad<br />
Richard Conrad<br />
Will <strong>and</strong> Billie Cr<strong>and</strong>all<br />
Jay Crary<br />
Frederick Davis<br />
David Deneka<br />
DePuy, Inc.<br />
Mohammad Diab<br />
Richard Diamond<br />
Oriente Ditano<br />
Ben <strong>and</strong> Nancy Ellison<br />
Ely Community Foundation<br />
Gregory Engel<br />
Edward <strong>and</strong> Cindy Farrar<br />
Jonathan Franklin<br />
Fzio Med, Inc.<br />
Michael Gannon<br />
R Gervin<br />
Robert Getz<br />
Park Gloyd<br />
Tom Green<br />
Ted Greenlee<br />
Ted Gross<br />
Larry D. Hull<br />
Doug Hanel<br />
Sigvard Hansen<br />
Harcourt, Inc.<br />
Brad Henley<br />
Highl<strong>and</strong> Medical Sales<br />
Joel Hoekema<br />
Scott Hormel<br />
Howmedica Osteonics<br />
Fredrick Huang<br />
Arlene Hundrup<br />
Mona Hundrup<br />
Phyllis Hundrup<br />
Thomas Hutchinson<br />
Larry Iversen<br />
Diana Jansen<br />
Daniel Jones<br />
Marci Jones<br />
Nancy Jordan<br />
Nancy Kadel<br />
David Karges<br />
Tom Karnezis<br />
Carlton Keck<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 67
Friends <strong>of</strong> Orthopaedics<br />
Richard M. Kirby<br />
Jonathan Knight<br />
Walter <strong>and</strong> Elizabeth Krengel<br />
Philip Kregor<br />
Ron Kristensen<br />
Joan F. Lane<br />
Melvin Lane<br />
Roger Larson<br />
Richard <strong>and</strong> Tracie Laughlin<br />
Allan Lichter<br />
George <strong>and</strong> Kathryn Lotzenhiser<br />
Tim Lovell<br />
George Luck<br />
Carl <strong>and</strong> Patty Magnuson<br />
James <strong>and</strong> Betty Malmassari<br />
Martin Mankey<br />
Frederick Matsen<br />
Gregory May<br />
Kathy McAffe<br />
McClure<br />
Robert McConnell<br />
Medtronic<br />
Michael Metcalf<br />
Merck<br />
William Mills<br />
Sohail Mirza<br />
Peter Mitchell<br />
Vince Mosca<br />
Marr Mullen<br />
David Nank<br />
Sean Nork<br />
Northwest Biomet<br />
William Obremskey<br />
John O’Kane<br />
William Oppenheim<br />
Orthopedic Physician Associates<br />
Pacific Rim Orthopaedic Surgeons<br />
Lawrence Page<br />
Jeffrey Parker<br />
Arnold Peterson<br />
Pharmacia & Upjohn Company<br />
Diane Plummer<br />
Christopher <strong>and</strong> Jessamy Powers<br />
Brett Quigley<br />
Gregory Rafijah<br />
Steve Ratcliffe<br />
Steven Reed<br />
Mark Remington<br />
Daniel Riew<br />
Kristine Roberts<br />
M.L. Chip Routt<br />
Michael Sailer<br />
Bruce Sangeorzan<br />
Mr. <strong>and</strong> Mrs. Sarah Sato<br />
Gregory Schmale<br />
James Schwappach<br />
Seattle Foundation<br />
Seattle H<strong>and</strong> Surgery Group<br />
Richard Semon<br />
Ge<strong>of</strong>frey Sheridan<br />
Curtis Shoemaker<br />
Peter Simonian<br />
Doug Smith<br />
Kevin Smith<br />
James Sobeski<br />
Kit Song<br />
Lyle Sorensen<br />
Lynn T. Staheli<br />
Jeff Stickney<br />
Edward Stokel<br />
Karl Storz<br />
Robert <strong>and</strong> Gladys Streiff<br />
Don Striplin<br />
Surgical Dynamics<br />
Marc Swiontkowski<br />
Synthes Spine<br />
Carol Teitz<br />
Allan Tencer<br />
William Thieme<br />
Michael Thorpe<br />
Irving Tobin<br />
Martin Tullus<br />
Dawn L.B. Trudeau<br />
Thomas Trumble<br />
United Way <strong>of</strong> King County<br />
Valley Orthopedic Associates<br />
Eric V<strong>and</strong>erho<strong>of</strong>t<br />
Nicholas Vedder<br />
Robert Veith<br />
Theodore Wagner<br />
William Wagner<br />
<strong>Washington</strong> H<strong>and</strong> Surgery<br />
Neil Wells<br />
John West<br />
Kenneth L. Williams<br />
Richard <strong>and</strong> Elizabeth Williamson<br />
Robert Winquist<br />
Jay Winzenried<br />
Wyeth-Ayrst Pharmaceuticals<br />
Wyss AO Medical Foundation<br />
Zimmer<br />
Joseph Zuckerman<br />
68 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Alumni<br />
1952<br />
Park W. Gloyd, M.D.<br />
1954<br />
Trygve Forl<strong>and</strong>, M.D.<br />
1955<br />
Robert W. Florence, M.D.<br />
1956<br />
J. Michael Egglin, M.D.<br />
John E. Goeckler, M.D.<br />
Robert L. Romano, M.D.<br />
1957<br />
John H. Aberle, M.D.<br />
John R. Beebe, M.D.<br />
1958<br />
Harry H. Kretzler, Jr, M.D.<br />
James R. Friend, M.D.<br />
Kenneth L. Martin, M.D.<br />
Samuel L. Clifford, M.D.<br />
1959<br />
James W. Tupper, M.D.<br />
1960<br />
Irving Tobin, M.D.<br />
William V. Smith, M.D.<br />
1961<br />
Robert C. Colburn, M.D.<br />
1962<br />
Arthur Ratcliffe, M.D.<br />
Marr P. Mullen, M.D.<br />
1963<br />
Alfred I. Blue, M.D.<br />
Robert A. Kraft, M.D.<br />
1964<br />
David E. Karges, M.D.<br />
Harold J. Forney, M.D.<br />
Theodore K. Greenlee, II, M.D.<br />
Thomas E Soderberg, M.D.<br />
1966<br />
F. Richard Convery, M.D.<br />
Joseph S. Mezistrano, M.D.<br />
William A. Reilly, Jr, M.D.<br />
1967<br />
Ivar W. Birkel<strong>and</strong>, M.D.<br />
J. Conrad Clifford, M.D.<br />
Robert F. Smith, M.D.<br />
1968<br />
Lynn T. Staheli, M.D.<br />
Stewart M. Scham, M.D.<br />
William T. Thieme, M.D.<br />
1969<br />
Edward E. Almquist, M.D.<br />
Edward L. Lester, M.D.<br />
Hugh E. Toomey, M.D.<br />
Sigvard T. Hansen, Jr, M.D.<br />
1970<br />
John C. Brown, M.D.<br />
John M. Coletti, Jr, M.D.<br />
Malcolm B. Madenwald, M.D.<br />
Michael T. Phillips, M.D.<br />
Robert D Schrock, Jr, M.D.<br />
1971<br />
Bruce E. Bradley, Jr., M.D.<br />
Franklin G. Alvine, M.D.<br />
Jerome H. Zechmann, M.D.<br />
Louis A. Roser, M.D.<br />
Nils Fauchald, Jr, M.D.<br />
1972<br />
David J. LaGasse, M.D.<br />
David R. Nank, M.D.<br />
Donald D. Hubbard, M.D.<br />
John A. Neufeld, M.D.<br />
Thomas L. Gritzka, M.D.<br />
1973<br />
Frederick J. Davis, M.D.<br />
Larry D. Hull, M.D.<br />
Robert P. Watkins, Jr, M.D.<br />
Theodore A. Wagner, M.D.<br />
1974<br />
Richard A. Dimond, M.D.<br />
Ronald S<strong>and</strong>ler, M.D.<br />
Samuel Baker, M.D.<br />
Robert A. Winquist, M.D.<br />
1975<br />
Donald L. Plowman, M.D.<br />
Frederick A. Matsen, III, M.D.<br />
Gunter Knittel, M.D.<br />
Larry R. Pedegana, M.D.<br />
Thomas M. Green, M.D.<br />
William M. Backlund, M.D., P.S.<br />
1976<br />
Douglas K. Kehl, M.D.<br />
Douglas T. Davidson, III, M.D.<br />
John F. Burns, M.D.<br />
Peter Melcher, M.D.<br />
Richard A. Zorn, M.D.<br />
1977<br />
Carl A. Andrews, M.D.<br />
Ge<strong>of</strong>frey W Sheridan, M.D.<br />
Larry D. Iversen, M.D.<br />
Mark C. Olson, M.D.<br />
Steven T. Bramwell, M.D.<br />
1978<br />
Arnold G. Peterson, M.D.<br />
Gary J. Clancey, M.D.<br />
John W. Brantigan, M.D.<br />
Richard S. Westbrook, M.D.<br />
Robert J. Strukel, M.D.<br />
William Oppenheim, M.D.<br />
1979<br />
Allan W. Bach, M.D.<br />
Gregory M. Engel, M.D.<br />
Jonathan L. Knight, M.D.<br />
Richard L. Semon, M.D.<br />
1980<br />
Carol C. Teitz, M.D.<br />
Douglas G. Norquist, M.D.<br />
John M. Hendrickson, M.D.<br />
Michael A. Sousa, M.D.<br />
Stuart R. Hutchinson, M.D.<br />
1981<br />
Dennis J. Kvidera, M.D.<br />
John M. Clark, Jr., M.D., Ph.D.<br />
Martin S. Tullus, M.D.<br />
Robert G. Veith, M.D.<br />
1982<br />
John L. Thayer, M.D.<br />
Richard M. Kirby, M.D.<br />
Steven S. Ratcliffe, M.D.<br />
William D. Burman, M.D.<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 69
1983<br />
E. Anne O. Elliot, M.D.<br />
Edward L. Farrar, III, M.D.<br />
Henry K. Yee, M.D.<br />
Joseph D. Zuckerman, M.D.<br />
Keith A. Mayo, M.D.<br />
Robert M. Berry, M.D.<br />
1984<br />
Jeffrey C. Parker, M.D.<br />
Jeffrey W. Akeson, M.D.<br />
Kevin P. Schoenfelder, M.D.<br />
Marc F. Swiontkowski, M.D.<br />
Thomas J. Fischer, M.D.<br />
1985<br />
Daniel L. Flugstad, M.D.<br />
Jeffrey N. Hansen, M.D.<br />
Paul J. Abbott, M.D.<br />
Richard J. Barry, M.D.<br />
William P. Barrett, M.D.<br />
1986<br />
Carleton A. Keck, Jr., M.D.<br />
Gary Bergman, M.D.<br />
Lawrence E. Holl<strong>and</strong>, M.D.<br />
Michael E. Morris, M.D.<br />
1987<br />
Craig T. Arntz, M.D.<br />
Herbert R. Clark, M.D.<br />
Michael K. Gannon, M.D.<br />
Steven L. Reed, M.D.<br />
1988<br />
Jonathan L. Franklin, M.D.<br />
Michael A. Thorpe, M.D.<br />
Richard V. Williamson, M.D.<br />
1989<br />
James P. Crutcher, M.D.<br />
Lawrence V. Page, DO<br />
Martin G. Mankey, M.D.<br />
Nancy J. Ensley, M.D.<br />
Steve C. Thomas, M.D.<br />
1990<br />
David M. Kieras, M.D.<br />
J. Roberto R. Carreon, M.D.<br />
Jay A. Winzenried, M.D.<br />
Ken Fujii, M.D.<br />
Walter F. Krengel, III, M.D.<br />
1991<br />
David H. Bishop, M.D.<br />
Kit M. Song, M.D.<br />
Mark Remington, M.D.<br />
Mark E. Murphy, M.D., Ph.D.<br />
Tim P. Lovell, M.D.<br />
1992<br />
Curt Rodin, M.D.<br />
Don Striplin, M.D.<br />
Eli Powell, M.D.<br />
Jeff Stickney, M.D.<br />
John D. West, M.D.<br />
Michael Sailer, M.D.<br />
1993<br />
J. Eric V<strong>and</strong>erho<strong>of</strong>t, M.D.<br />
Lyle S. Sorensen, M.D.<br />
Philip J. Kregor, M.D.<br />
Susan R. Cero, M.D.<br />
1994<br />
Brodie Wood, M.D.<br />
Eric Bowton, M.D.<br />
Jim Vahey, M.D.<br />
Sohail K. Mirza, M.D.<br />
William Obremskey, M.D.<br />
1995<br />
Ron Kristensen, M.D.<br />
Scott Hormel, M.D.<br />
Timothy Beals, M.D.<br />
Todd Clarke, M.D.<br />
William J. Mills, III, M.D.<br />
1996<br />
David Deneka, M.D.<br />
Peter Mitchell, M.D.<br />
Peter T. Simonian, M.D.<br />
Vernon Cooley, M.D.<br />
William Wagner, M.D.<br />
1997<br />
Daniel Stechschulte, Jr, M.D.<br />
David Levinsohn, M.D.<br />
L. Anthony Agtarap, M.D.<br />
Mohammad Diab, M.D.<br />
R<strong>and</strong>all W. Viola, M.D.<br />
1998<br />
Colin Poole, M.D.<br />
David Belfie, M.D.<br />
Don Ericksen, M.D.<br />
Jay Crary, M.D.<br />
Oriente DiTano, M.D.<br />
1999<br />
Craig Boatright, M.D.<br />
Jeffrey Garr, M.D.<br />
John Michelotti, M.D.<br />
Julie A. Switzer, M.D.<br />
Thomas D. Chi, M.D.<br />
2000<br />
Brett Quigley, M.D.<br />
Cara Beth Lee, M.D.<br />
Daniel Jones, M.D.<br />
Joel Hoekema, M.D.<br />
Patrick McNair, M.D.<br />
2001<br />
Eric Novack, M.D.<br />
Frederick Huang, M.D.<br />
Matthew Camuso, M.D.<br />
Michael Metcalf, M.D.<br />
Richard Bransford, M.D.<br />
<strong>2002</strong><br />
Timothy DuMontier, M.D.<br />
Scott Hacker, M.D.<br />
Timothy Rapp, M.D.<br />
William Sims, M.D.<br />
Carla Smith, M.D.<br />
70 <strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT
Endowments<br />
We express our appreciation to all who have contributed to the endowments <strong>of</strong> the Department <strong>of</strong> Orthopaedics <strong>and</strong> Sports<br />
Medicine. Your assistance makes possible special research activities, educational programs, <strong>and</strong> other projects that we could<br />
not <strong>of</strong>fer without this extra support from our alumni, faculty, <strong>and</strong> friends in the community. Additional Contributions to<br />
these <strong>and</strong> new endowments are most welcome! If you have any questions, please contact our Chair, Rick Matsen, or our<br />
Administrator, Diana Jansen.<br />
THROUGH APRIL <strong>2002</strong><br />
Ernest M. Burgess Endowed Chair for Orthopaedics Investigation<br />
Jerome H. Debs Endowed Chair in Orthopaedic Traumatology<br />
Endowed Chair for Women’s Sports Medicine <strong>and</strong> Lifetime Fitness<br />
Victor H. Frankel Award<br />
Sigvard T. Hansen Jr. Endowed Chair in Orthopaedic Traumatology<br />
Douglas T. Harryman II/DePuy Endowed Pr<strong>of</strong>essorship for Shoulder Research<br />
Don <strong>and</strong> Carol James Research Fund in Sports Medicine <strong>and</strong> Fitness<br />
John F. LeCocq Lectureship in Orthopaedic Surgery<br />
Orthopaedic Traumatology Endowed Lectureship<br />
Ostex <strong>Bone</strong> <strong>and</strong> <strong>Joint</strong> Research Endowment<br />
Spine Research Endowment<br />
AO Medical Foundation/Wyss<br />
Surgical Dynamics Endowed Chair for Spine Research<br />
Zimmer Fracture Fixation Biology Endowed Pr<strong>of</strong>essorship<br />
<strong>2002</strong> ORTHOPAEDIC RESEARCH REPORT 71